Would you report this error?

[caffeinatednurse, BSN, RN]

I recently started a new job.

Recently, during narc count, I caught 2 mistakes made by the off going nurse. One mistake involved a narc given at the wrong time - the medication was due to be given on my shift, but for whatever reason, it was given on that nurses shift. The second mistake involved giving the wrong dosage of a narc.

The nurse admitted the mistakes to me, and reassured me that they would fill out an incident report and "write it up." However, I'm becoming concerned that they never followed through on that. When I looked back at the narc record, this nurse has since crossed out the time that the narc was actually given and listed the prescribed time - a time during my shift! Which makes no sense...how do you sign off on a drug that you weren't there to give?

For the record, I did not sign off on the drug for a second time since it was a once a day dose. I documented in MAR that it was given earlier in the day by the previous shift.

I really don't want to anger this nurse since their personality makes me a little weary of them anyway - they're quick to anger, impatient and seem pretty insecure at times - but I'm concerned that this was never mentioned to a supervisor. I don't want their mistake to fall back in my lap, for many reasons, but especially since this nurse signed off that the med was given on my shift, when it wasn't.

I also don't want to paint a target on my back at my job, since I'm still new and I can't do my job if I don't have people at work I can ask questions, work with, etc. But at the same time, I have to protect my license and the people I take care of.

What would you do?

[angeloublue22, BSN, RN]

Of course you should report this. She made medication errors and falsified documentation. Those are serious issues. The fact that someone is prickly should never overrule your ethics or accuracy. I have to think this is not the first time or last time she would falsify medical records. You are absolutely right that this could fall back on you. Is she worth the risk to you?

[canoehead, BSN, RN]

Report it to protect yourself.

[AlwaysLearning247, BSN]

I would definitely report it. You're responsible for the narcotic on your shift and you didn't give it, she documented she gave it on your shift. Definitely report it to protect yourself!

[Khaan]

Yes, especially because it involves narcotics. It needs to be solved.

[Ruby Vee, BSN]

Report the facts only, not what you think or feel about the facts. The med was recorded as given early, then the documentation was changed. As for the incorrect dose, the narcotic count should reflect that and you should always report an incorrect narcotic count that you cannot resolve.

[caffeinatednurse, BSN, RN]

Report the facts only, not what you think or feel about the facts. The med was recorded as given early, then the documentation was changed. As for the incorrect dose, the narcotic count should reflect that and you should always report an incorrect narcotic count that you cannot resolve.

Thanks for your reply.

I spoke with the supervisor re: the med errors in questions, but the one w/the time change in particular since it was listed as being given on my shift. I mentioned the other error, but they didn't seem as concerned about that one - maybe because it's been reflected on the sheet, as you pointed out. Anyway, they said they would look into why the time was changed.

In hindsight, I should've just stopped the narc count and asked a supervisor to review the situation before continuing on. Then it would've been reported and I wouldn't have had to worry about it later. Lesson learned.

[Gennaver, MSN]

Hello,

edit: your right, it involves narcotics, I'd get that cleared up quickly.

I would let the nurse know what you came across, in a respectful teamwork way. I'd also let her know that you wanted to give her the chance to annotate the error and to write any Patient Safety report, (whichever your institution uses.)

I think the person who caught the error can be the one to write the report but I also feel it is courtesy to let the person who did the error write it themselves too because in there they have an option to say what would prevent it from happening again and there maybe a system in place that caused the error that you are not aware of but she is.

Jen

[3ringnursing, BSN]

It makes me wonder if the pt even received the medication at all. I'm not so sure someone isn't looking into this. Pharmacy are usually sticklers for correctness.

[rubynrse, ADN, RN]

Unfortunately throughout my long career as a nurse in many different venues and through many decades I've found that management, especially middle management, want things to run smoothly. This includes keeping the employees with a more high-strung personality content. They don't like the boat rocking. It's almost as if there is a different hierarchy of "errors" than the ones that exist in the NLN and/or the oath we took at graduation. I've been both the "floor" nurse and middle management.

What I've learned? Listen to your heart, beliefs, and sense of ethics and morals and do what you think is right no matter what the outcome. All you can ever do is the right thing. You have no control over what people who receive that information do with it. It's how I sleep at night.

[susummers1]

Definitely let your supervisor know. Did you talk with the patient to see if they did in fact receive their medication early that one day? The person did own up to the mistakes to you but if she did not inform the supervisor or "write up" the mistakes as they mentioned they would, I would worry about medication diverting. Some of the things you said "quick to anger, impatient" make me question if this could be a reason. It's always best to remember it's your license and you want to protect it, you worked hard for it.

[Elfriede]

1.) Note it down.

- The facts and only the facts.

2.) Copy it. (By hand)

(Don´t use a Hospitalcopier. - Copiers save everything or/and send it to theire network.)

3.) Keep the original and carry the second one to your supervisor. Immediately.

"Narc-Trouble" may brings you - next to the lost of the licence - a few years of "Federal-Care".