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Would you report this error?


Specializes in Med-surg, telemetry, oncology, rehab, LTC, ALF. Has 4 years experience.

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?

Edited by caffeinatednurse

angeloublue22, BSN, RN

Specializes in Addictions, psych, and corrections. Has 7 years experience.

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

Specializes in ER. Has 30 years experience.

Report it to protect yourself.

AlwaysLearning247, BSN

Has 4 years experience.

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!

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

Ruby Vee, BSN

Specializes in CCU, SICU, CVSICU, Precepting & Teaching. Has 40 years experience.

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

Specializes in Med-surg, telemetry, oncology, rehab, LTC, ALF. Has 4 years experience.

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

Specializes in Ortho, Med surg and L&D. Has 13 years experience.


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.


Edited by Gennaver

3ringnursing, BSN

Specializes in ICU; Telephone Triage Nurse. Has 25 years experience.

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

Specializes in Hospice, Geriatrics. Has 40 years experience.

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.


Specializes in Trauma Med Surg, Telemetry, Education. Has 8 years experience.

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.


Specializes in ambulant care. Has 40 years experience.

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".

Creamsoda, ASN, RN

Specializes in ICU.

Dear god yes. She is trying to cover her tracks. Report report report. Dont tell her you filed an incident report. Just file it and management will deal with it then. If she asks you about it tell her you take your job and license seriously and you cant have that kind of mistake associated with you.

Filling out an incident report is the right thing to do. We fill out incident reports even for smaller errors like forgetting a cap or dressing change, or expired lines. The purpose isn't to go after your fellow nurses. Its to protect patients so that these errors are not further made. If no one reports them, then there will be no one to remind all of the nurses that this isn't okay behavior. Rarely on my unit do we actually get in trouble for making errors like this, as long as it is reported and improvement is made.

I most certainly would report the errors, also letting the supervisor know that the RN who made the error had falsified a document showing that you gave the medication, which you didn't. Obviously you are not yet using EHR's in your facility, because she would have been unable to cross out the time and amend it to show that the med had been given on your shift. Obviously this RN isn't too intelligent, because I would like to hear her explain how she gave the med on your shift as she had documented. I would also let the surpervisor know that you fear retaliation from this RN, which would create a hostile workplace for you. This is a serious offense and should not be taken lightly. Whatever you do make sure that you keep copies for yourself, minus the patient's name as that would be a HIPPA violation.

Edited by SallyRNCNOR

Murse901, MSN, RN

Specializes in Emergency, Case Management, Informatics. Has 13 years experience.

Recently, during narc count

I honestly stopped reading after that. Yes. Whatever the question is, if it's related to narcotics, report it.


Specializes in Orthopedics/Trauma/Med-Surg.

I agree with your thoughts and advice. All you can ever do in life is what you believe is the right thing to do. You are so very correct about how middle mgmt operates. I went to my manager about an incident and kept the conversation patient oriented. I did not name other nurses, just stated that there were interventions that could have made the patient more comfortable.

The manager told the individual nurses that I tattled on them which painted a big target on my back. The manager encouraged gossip and used the "divide and conquer" method of management. I eventually left that hospital.

BUT I was proud of myself because I did what was right for the patient. None of us can control what other people do or how they behave. We can do what is right for our patients and ALWAYS protect your license.

Always report narcotic errors. This nurse either is not following protocol or is diverting drugs. Since you are verifying the narcotic count, it will fall back on you if you document the count as correct and it is not.

I know of two nurses where I worked that diverted narcotics for months before they were caught because no one wanted to "rock the boat." Another nurse almost lost her job because she signed in to witness a pharmacy tech restocking narcotics but did not stand there to actually count with the tech. The pharmacist held her responsible when drugs were missing.

Protect your license; always report.