Why is it my fault?

Pediatric Critical Care Columnist · Jul 10, 2008

I would consider it the responsibility of the nurse who sent the specimen to also send the req. In the real world, stuff happens and reqs don't get sent. It's not your fault, and filling out an incident report on this situation would reflect that. When filing an incident report, one explains what happened (or in this case didn't happen) and what steps were taken to rectify it. That's all. You may have to identify the nurse who should have sent the req with the bag, and you will have to identify yourself as the one filing the report and the one who discovered the error. That should be IT.

imanedrn · Jul 10, 2008

I would consider it the responsibility of the nurse who sent the specimen to also send the req. In the real world, stuff happens and reqs don't get sent. It's not your fault, and filling out an incident report on this situation would reflect that. When filing an incident report, one explains what happened (or in this case didn't happen) and what steps were taken to rectify it. That's all. You may have to identify the nurse who should have sent the req with the bag, and you will have to identify yourself as the one filing the report and the one who discovered the error. That should be IT.

:yeahthat:

Sounds about right to me!

Scrubby · Jul 11, 2008

When you say that you asked everyone did you ring the lab and ask them about the order because they are the ones who wrote it? Sometimes it's worth going back to the direct source and asking them to clarify something rather than just asking your fellow coworkers.

Perhaps an incident report may help improve orientation in your area to include cytology slips. When you do an incident report make sure that they are aware that you were not told the protocol.

**canoehead, BSN, RN** · Jul 11, 2008

She said that cytology closes at 5pm and she is a night nurse.

Medic2RN, BSN, RN, EMT-P · Jul 11, 2008

I was once in a similar situation. Some order was not followed on the day shift prior to mine. The doctor screamed and yelled at me and then my supervisor verbally reprimanded me for something that happened (or not happened) on a day I was off work.

I was told that during report, I (or any nurse) receiving report would be responsible for the prior 24 hrs of orders when I took control of the patient.

So now, in addition to the gazillion of other things a nurse must miraculously do, when I take report from the previous shift, I have the chart in front of me and verify that everything was done or not done, so I can make sure it happens.

It's tedious, it's time consuming, and I'm not petty, but I don't enjoy getting in trouble for things I have no control over.

Perhaps chart checking during report will prevent it in the future. I do the same as you, live and learn. I agree though, the responsibility was that of the day shift.

MaryAnn_RN · Jul 11, 2008

last week the consultant was going through the icu chart which is massive, loads of info on it. He was clearly looking to find a problem, but couldn't find one on the chart for that particular day. Flips the chart up to look at the chart for the preceding day and went 'ARRRRRR WHY NO ENTRY ON THIS HOUR AND THIS HOUR' at the top of his voice, eyes bugging out...you get the picture. Well, I lifted the top chart up a little further and there it was 'pt in theatre' for those 2 hours...on my day off. No apology, just stomped off without a word.

It seems like it is always the fault of the nurse on shift at the time the problem is discovered and it is not on.

imanedrn · Jul 12, 2008

Perhaps chart checking during report will prevent it in the future. I do the same as you, live and learn. I agree though, the responsibility was that of the day shift.

We're required to do 12 hour chart checks during shift report. Until I read on this website that some places do NOT do this, I just assumed everyone did. It makes such great sense!

The nurse from the off-going shift reviews the orders from HER shift with the nurse of the on-coming shift. It's the off-going nurse's responsibility to make sure all her orders are in. If she didn't do them (i.e., an MRI is ordered during the night shift but can't be done at night, so it's handed off to the day shift nurse to ensure it's done), then it's her responsibility to tell the on-coming nurse. We sign the chart together as a "12 hour chart check" which indicated that we've both reviewed the orders for the previous 12 hours, and they are set and ready to go. If there are any discrepancies (i.e., a med isn't on the MAR), then the off-going nurse is expected to reconcile the issue or at least let the on-coming nurse know about it. For example, an MRI had been ordered early in the day on my shift. I called down to MRI several times to find out when the pt was going but never got a response. (Weird fluke...) I informed the night nurse of this, so it could be passed on to the next day nurse, since I wouldn't be back the next day.

If something was ordered on, say, the previous shift -- another 12 hours prior to the shift prior to mine -- I am NOT responsible for that. Now, there are some nurses who are very "thorough" and will review ALL previous orders, but we are not required to. That's the whole reason for doing a TWELVE hour chart check TOGETHER.

There was one instance where a narc was d/c'd on the day shift prior to mine. Apparently, this was not caught during the previous chart check, nor did the pharmacy remove it from the pt's MAR. (Our MARs are electronic; the pharmacy adds & removes all meds.) Several shifts after the med was d/c'd, nurses continued to give the pt this med (including me). I only found out when I worked several days later (it was caught somehow) when I was told an "incident report" had been filed, but I didn't get written up or anything. I don't know what happened to the 2 nurses who should have caught it, but I know they're still working with us.

CABG patch kid, BSN, RN · Jul 12, 2008

It's definitely a live-and-learn thing. My example: an order had been written at 1000 for 2gm Mag Sulfate IVPB. I come in at 1900, forget to go over orders with the day nurse. I have a busy night but sit down to do my 24 hr check at 0200.... I see the Mag Sulfate a few pages back and think "oh noooo", call pharmacy to find out if it was ever mixed and sent over and it never was. Needless to say, the pt did not receive his Mag until about 18-19 hrs after the order was written. I had to reschedule am labs to reflect the Mag level after the pt got the Mag.....

Moral of the story is, I always check the orders now because I don't need this worry in the back of my mind the whole shift. Since we use an electronic MAR, I also check to see that the previous shift documented their meds so I'm not wondering if it was actually given later on. It does make report a bit longer and some nurses still act like this is a foreign thing to do each and every shift change, but its so necessary.

I hope I didn't sound preachy or anything, its just coming from one new grad to another. We learn from our mistakes, in this case just know that you weren't the one to majorly drop the ball here, and don't be afraid to name names of the person who did.

Medic2RN, BSN, RN, EMT-P · Jul 12, 2008

If something was ordered on, say, the previous shift -- another 12 hours prior to the shift prior to mine -- I am NOT responsible for that. Now, there are some nurses who are very "thorough" and will review ALL previous orders, but we are not required to. That's the whole reason for doing a TWELVE hour chart check TOGETHER.

Yes, we also do a 12 hour chart check, but now I do a 24 hr one. That instance was not the first time I have had a chunk of butt taken from me for something the prior day shift did not complete. We are suppose to be responsible for the previous 12 hours and our own shift, but I guess that isn't the case when there is an angry doctor calling for heads to roll. Whoever the present nurse is for that particular patient will receive the brunt of it from the doctor and then supervisors will soon follow.

At least this happens on my unit.

SoundofMusic · Jul 13, 2008

Sounds like a live and learn thing to me.

Thanks for posting it, as I will be more careful at shift change myself with the charts.

Our unit NEEDS to do this -- to go over the past 12-24 hrs and sign it off together, with he chart. It's way too casual -- and things like that can easily be missed. They insist on this voice care thing where we record report, but I think it's as easy to just review the chart together and do a verbal report. Might take time, but it's more thorough.

Our nurses usually take off before you've even seen the chart together. It's scary.