Tattle Tale?

[andsoitis]

An Rn missed a prophylactic heparin drip protocol that was supposed to be started after a patient's surgery which was the start of his shift. I noticed it at the start of my shift and discussed with the prior RN. The patient is fine but technically we are supposed to report errors like this in our database system. This eventually goes to the charge nurse who does an informal discussion with that RN asking what could have been done differently and then our unit is made aware in an update of reports though no name is given. So I don't normally write these reports unless there was potential serious harm to the patient because all nurse make mistakes. Sometimes I have a hard time determining what is serious if the patient wasn't injured. But to me it seemed serious not to start a heparin drip after a surgery and I feel like something like that could be missed again by other nurses since these protocols aren't scheduled like how medications have timed administration. But i feel like such a tattle tale especially when these same nurses have helped me with questions in the past. I feel like they'll be mad at me and not want to help me after I've "tattle taled." BUt at the same time I want to cover my butt and be a patient advocate and correct system issues. Thoughts?

[CodeteamB]

Here's how I see it.

1- a serious error was made, this needs to be addressed

2- I assume that the fact that a heparin gtt was delayed for hours ( the RN's whole shift from the sound of it) was reported to the responsible physician, the patient and the charge nurse. It should not be a question of telling or not telling.

3- by not reporting you become complicit in the situation

4- it sounds like your workplace has a good way of dealing with these incidents (treated as a learning opportunity rather than as discipline)

Basically it seems to me from my understanding of your post that you really should do an incident report. I would inform your co-worker that you are doing something so he does not feel like you are going behind his back and explain your reasons for doing this. I know how you feel, it can be really intimidating/ make you feel bad. Remember you have a duty to your patients and yourself.

Good Luck!

[Morainey, BSN, RN]

It could be addressed in such a way that it wouldn't seem like tattling. You could bring it up to your manager/clinical leader/charge nurse or whoever that it's an easy protocol to miss, especially in a hectic post-op or change-of-shift setting, and suggest specific improvements. If you already brought it to this nurse's attention, I don't think it's a good idea to name that person specifically.

[amoLucia]

In a gentle way, you might ask that other nurse if s/he did the incident report already. Because an incident report is REQUIRED, you're just asking to make sure that it WAS completed - just so YOU don't get in trouble for its omission. And then you offer to do it if the other nurse seems reluctant to do so. After all, you're just following P & P.

[applewhitern, BSN, RN]

You seriously wonder what other nurse's "thoughts" are on this matter? An incident report needs to be done. This will help determine how the heparin got missed, and what needs to be done to avoid these types of errors next time.

[Tait, MSN, RN]

You seriously wonder what other nurse's "thoughts" are on this matter? An incident report needs to be done. This will help determine how the heparin got missed, and what needs to be done to avoid these types of errors next time.

This. Incident reports are intended to find errors in process, not place blame. I would feel more tattled on if a nurse went to the manager, than if they followed the hospital incident report procedures. Even if the other nurse had already done the incident report, if I found on my shift I would fill out the report using the basic information available.

By circumventing what sounds to be a very standard protocol for reporting errors, it sounds like one is going out of their way to bring the error to the attention of managers, which like I said to me is more the definition of tattling.

[imintrouble, BSN, RN]

You're personalizing the whole situation.

If this had happened to another nurse, on another unit, would you still have trouble seeing the obvious course of action?

An incident report at the least.

[chrisrn24]

I will typically tell the nurse, "just a heads up, I had to fill out an incident report because I noticed that patient X blah blah blah."

I've had to fill out incident reports about other nurses and other nurses have had to fill them out as well on me. It is nothing personal.

[jadelpn, LPN, EMT-B]

This is not "tattling". It is a procedural hiccup that could cause patient harm. You even noted where the problem seems to be (no scheduled protocol) so that is a procedural issue that needs to be corrected.

An incident report is not meant to be disciplinary. (and yes, in some facilites, sometimes that is not the case).

However, seems like anyone could forget to give this infusion, therefore, there needs to be a change.

And some re-education for all the nurses on what the protocols/standing orders are for surgical patients and other specialized procedural orders.

[OCNRN63, RN]

You seriously wonder what other nurse's "thoughts" are on this matter? An incident report needs to be done. This will help determine how the heparin got missed, and what needs to be done to avoid these types of errors next time.

Indeed!