What would you do in this situation?

[NurseyPoo7]

We had a drop in census the other day, and 2 nurses were pulled to other units. Luckily, both of them were the ones with all the discharges/transfers, so both of their groups combined had maybe 4-5 patients in them that I was told the charge nurse was taking. It was 4pm by the time they all left, so there was only 3 hrs left in the shift... we'd be OK.

So, around 530-6pm, I get a call from another nurse who was just there organizing/setting up some new things for us asking if I knew this one patient of mine was being discharge as he has been waiting for awhile. I told her, I didnt have that patient.. I already have 5-6 patients and one of which had just gotten to the floor as a new admit.

The nurse then tells me the charge nurse told me it was my patient. I told the nurse, "Well if it is my patient, I don't know anything about them... havent gotten report and dont even know the patients name or Dx!". The other nurse was nice enough to do his d/c for us. I talked to her later on and she said I needed to do an incident report on it. I had happened to look up the patients info and noticed he had overdue meds from 4pm on! including an FSBS and insulin coverage!

I went to the charge and asked her if that patient really was mine and she said Yes. I told her I wasn't made aware of that, which she responds to with "Oh... wait. That is my patient. Sorry I forgot."

What would you do? (I also called our NM to make her aware of the situation. She agreed an incident report would be OK just to cover my butt in case the patient complains or brings up legal action)

[RNsRWe, ASN, RN]

I'd do just what was already done. The discharge was done by another nurse, not you, so your name isn't on anything there. The overdue meds, etc are on the name of the charge nurse who "forgot" she had that patient; clear cut neglect case.

You've already notified your NM, he/she said to do an incident report, which I'd be pretty quick in completing. Should her name mysteriously be erased and YOUR name be written in, it'll be on file whose patient that really was. CYA, baby.

[Vito Andolini]

Are your assignments in writing?

How can a charge nurse carry such a large assignment and still Charge?

I don't think you should write anything except for your own file.

[NurseyPoo7]

Are your assignments in writing?

How can a charge nurse carry such a large assignment and still Charge?

I don't think you should write anything except for your own file.

Well, it was only 4pm or so by the time she even picked them up. We get off at 7pm, so there was only 4 hours and a few of those patients were walky talkies, had little meds to give, etc... She had an easy group.

Our assignments are in writing, but when staffing changes in the middle of the shift, it is never ever updated.

[Tweety, BSN, RN]

Remember you aren't "writing her up", you're only documenting for the record an incident that also included a med error, on the unlikely chance something comes up later. Also it might help identify what want wrong, but clearly the charge nurse made a human error in forgetting. It's understandable, but an error occurred nonetheless.

[NurseyPoo7]

Remember you aren't "writing her up", you're only documenting for the record an incident that also included a med error, on the unlikely chance something comes up later. Also it might help identify what want wrong, but clearly the charge nurse made a human error in forgetting. It's understandable, but an error occurred nonetheless.

Right, I'm not trying to get her in trouble (although, I personally would not like her to be my own nurse if I was in the hospital). I am just trying to cover my OWN butt in case something happens.

[NightshiftRN69]

It would seem to me that if the assignment changes at any time during the shift and the written assignment is never updated that is just asking for this type of thing to happen or even worse what if the patient had been prescribed parkinson meds that are needed every two hours or anticonvulsive meds. That is one practise that needs to be changed - the assignment sheet should always be updated, what if the person who recieved report on the patients suddenly got hurt or had to leave the floor for any reason if had time to report off but forgot she had a patient or two then what would happen. Major unsafe situation.

[TopazLover, BSN, RN]

A report certainly is in order. I look at these reports as a way of discovering systems errors. In this case it is clear a systems error of lack of documentation of assignments as they change was one of the problems.

You might find other errors exist in this situation.

Just to complete the report and have it filed is a waste of time. these need to be learning tools. How do we prevent this in the future? What happens to the reports? Who reviews them and what is sent back to the nurse on the floor as to how to prevent in future?

I am sorry you were stuck in the middle of the usual ***** that sometimes happens in a busy area. Use this experience and see if your NM is willing to get assignments updated in writing for all to see and review as necessary.

[NurseyPoo7]

A report certainly is in order. I look at these reports as a way of discovering systems errors. In this case it is clear a systems error of lack of documentation of assignments as they change was one of the problems.

You might find other errors exist in this situation.

Just to complete the report and have it filed is a waste of time. these need to be learning tools. How do we prevent this in the future? What happens to the reports? Who reviews them and what is sent back to the nurse on the floor as to how to prevent in future?

I am sorry you were stuck in the middle of the usual ***** that sometimes happens in a busy area. Use this experience and see if your NM is willing to get assignments updated in writing for all to see and review as necessary.

All our incident reports go to Risk Management -- if anything needs to be fixed, they come up and discuss the issues with the NM or the nurses... and they will attempt to fix any problems so the issues isnt repeated again. We try and use them as learning experiences.