Worried About Going to Management, Admitting to Mistake, and Doing the Right Thing

[BeatsPerMinute, BSN, RN]

Hey everyone, would appreciate some thoughts on this situation and what you might do if in a similar one.. 

I work in the ICU. Recently I had a patient who went into Afib RVR. 2-3 residents were with me and instructing me while I was helping this patient and they had the attending on the phone as well. All were guiding me on what to do. While trying to "fix" the issue with the patient I ended up down titrating, up titrating multiple gtts. Patient was all good after it. 

Later that day, my charge nurse approached me, nervously. She admitted that she didn't know how to handle the fact that she witnessed that one of the gtts I was up titrating and down titrating that is a gtt that is required by the hospital to document VERY accurately via EMR & via an extra paper slip. She witnessed me making changes to the gtt but it had slipped her mind to do the whole "dual sign off thing". It had slipped my mind as well since I was more focused on the patient. Follow up comment which was "but you didn't tell me that you needed a witness and you didn't ask me" which is a bit frustrating and it sounds like its all coming from a fear based place. 

I said that we could correct it all, and then she said no to that, because too much time had passed and she couldn't remember the exact times, and therefor wasn't going to put her name behind it. 

I shared that I did remember the times and showed her the chart: patient HR was increased at X time and that was when I increased the gtt, and patient HR was corrected at Y time, which was when I went back down on this gtt. Charge nurse repeatedly said that she didn't know what to do, and told me no to any sort of back charting, especially since several hours had passed since the incident happened.

I am still learning the ropes of this facility. She shared that this facility takes some things VERY VERY seriously, and that it is a a big deal if a nurse fails to document any changes with this particular drip if not documented in real time via EMR and on a separate paper file. 

I completely understand the concern that she has... however I do not understand that when there's an emergent situation going on, and when acting in a responsible way, having support there guiding me all along the way, totally focused on the patient and keeping them safe and that they are safe and sound how the documentation process could possibly trump proper and safe patient care. 

Do I approach unit educator, or even my manager? I can humbly admit to the mistake and that in the future that I will do things differently, and sincerely want to know what their take would be on the situation. Educator, manager and nurse director are very kind, understanding people. The rare down to earth kind that one can find in nursing LOL.

I don't like the idea of fear driving my decisions, and I really am thinking about going to them and sharing the experience and asking what their expectations would be. Totally open to correction. A little concerned again about how anxious the charge nurse was over the situation. (Side note, curious if it make a difference at all: The charge that day is NOT full time staff. She is a traveler. she also has like 20+ years of experience more than I do. So she might have seen / experienced some things that I have not yet experienced) 

Thoughts? 

[JBMmom, MSN, NP]

I think the bigger problem right now is that as you relay this situation it sounds like at this point a few days have passed, not just hours. I think that when I realized there was an issue, I would have reached out in real time to find someone to fix the situation. It's unfortunate that a traveler was in charge at that time, so maybe not the best informed on the particular policies of the unit. 

It doesn't sound like any actual med error occurred, so I don't think there's a huge problem. But, I don't know the medication you were titrating or your hospital/pharmacy policies so that could be inaccurate. I'm thinking from a patient safety standpoint. 

I would definitely reach out to an educator, manager or assistant manager and say that you need to clarify the policy related to that particular drip. And then explain the situation and that you had no prior knowledge of the need for paper charting on it. Good luck.

(for what it's worth, I find the whole paper charting in addition to EMR charting to be a ridiculous waste of time and resources and I'm convinced that half the time no one ever even looks at the paper record)

[sleepwalker, MSN, NP]

FWIW....Just my 2 cents but double documentation just opens up to potential conflicting documentation (I.e. EMR says one thing and paper documentation may say another by mistake or vice versa). Lawyers love that crap....now you have to explain why one set of documentation says "this" and the other says "that". It becomes a situation of you're either incompetent with documentation or lying...lawyers don't care which...it's a no win situation.

[Been there,done that, ASN, RN]

"one of the gtts I was up titrating and down titrating that is a gtt that is required by the hospital to document VERY accurately via EMR & via an extra paper slip. " I have been in acute / ICU care for 30 years. I have NEVER seen EMR and paper documentation required. 

Charge nurse stated "She witnessed me making changes to the gtt but it had slipped her mind to do the whole "dual sign off thing". So... she is as "guilty" as you of not making a paper trail.

You did nothing wrong. It is an antiquated system.. that would actually take time away from the rapid response.

[mimibrown, ADN, BSN]

I think in an emergent situation, some protocols get missed. If no harm was done to the patient and you documented everything, I can’t see how it would be a huge deal. I would reach out to the educator and ask for clarification on the policy. The charge nurse should have told you that day. 

[2BS Nurse, BSN]

If this was an emergent situation, shouldn't she have documented for you so you could enter into the EMR after the situation was settled?? 

Double documentation in EMR and on paper? Who does that??