Would you report this error?

[caffeinatednurse]

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?

[Creamsoda, ASN, RN]

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.

[edilleyrn]

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.

[SallyRNCNOR]

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.

[Murse901, MSN, RN]

Recently, during narc count

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

[NextGen]

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.

[blyrn1958]

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.

[acparry]

yes.

It is not easy to report a fellow nurse. Our obligation is to safe patient care, not to protecting our colleagues. I did it once about 15 years into my 35 plus years nursing. I was a casual RN working with a regular night nurse who was inappropriately heavy-handed with patients. I asked myself "what i would want if one of my family members was treated like that" - or as in your case, missing a medication they needed. Not everyone has a straight/north moral compass or sense of duty to care. In another hospital's ICU situation, I refused to be charge nurse for the night shift because it also meant being in charge of all the ventilators - there was no RT, no RN supervisor who could manage vents, no doc, no intern - just me. I called RNAO and asked someone what to do. I was advised the following - "In a court of law, you would be asked to dismantle a ventilator and put it back together - if you don't think you can do that, then do not put yourself in the RN in charge". So - I spoke to the ICU head nurse and she rescheduled. Needless to say, I was ridiculed by some other nurses. I held my head high, did my best at work and was grateful that I would be soon returning to BScN studies and would not have to work there for much longer.

If I was you, I would probably go to a nursing supervisor first, in case the head nurse is not keen to follow your claim or is intimidated by the process ("tone at the top" as they say...). State just facts - do not pass judgement; ask to keep your name out of it until absolutely necessary. If the climate in the hospital/work environment does not seem supportive of reporting (i.e."nurses eat their young"), then call your Nursing Association or licensing body before proceding.

Peer pressure is a ***** and no one wants to be labeled a narc.

But ask yourself - in 20 years what action will your future self be proud of?

[caffeinatednurse, BSN, RN]

Thank you all of your input.

The error has been reported to my supervisor. At our facility, the person who made the mistake fills out the incident report, so it's up to the supervisor to ask the employee to fill one out. Hopefully, management takes it as seriously as I do.

I am keeping a copy of the dates, medications & dosages (without names or identifiers) in case it pops up in the future and there's any questions. Also the date that I notified my supervisor. I do wish I had notified management in writing, but they've been notified, nonetheless. I can only hope that they do their job. In the mean time, I've done my job & protected my license & the people I take care of.

I'm glad to see my thoughts about this incident were on par. I've never encountered anything like this before, primarily because I worked in acute care before this job & it was next to impossible to "hide" an error. If someone at my last job tried to, pharmacy would catch it & report it to your supervisor. Not to mention, I've always held myself 100% accountable for my mistakes. I guess there's plenty of nurses who don't... It definitely makes me more guarded w/my nursing practice than I was before, which is not such a bad thing given my lack of experience.

[Alex_RN, BSN]

I will be quite honest here. I have made similar mistakes when I was new and more experienced nurses showed me how to balance things out without drawing attention to it. To be clear, there was no risk of patient harm and no diversion, just an honest mistake. Just last week, a new RN made the exact some mistake I had made a year before, but twice during her shift. She was agonizing over her error, as I had the year before. I jumped in and showed her how to clean it up/cover her tracks with no undue attention being drawn to it. Another experienced RN jumped in to double-check our work to make sure we did it right so that nothing would be flagged in an audit or by the pharmacy. It took about 15 minutes for all three of us to straighten it out, working together. Neither that RN nor I will ever make that mistake again.

It sounds like the OP was describing a pattern of sloppiness or worse, but sometimes you just work together to minimize the disruption and move on. We work hard and we learn from our mistakes. We are only human.

[Ruby Vee, BSN]

I will be quite honest here. I have made similar mistakes when I was new and more experienced nurses showed me how to balance things out without drawing attention to it. To be clear, there was no risk of patient harm and no diversion, just an honest mistake. Just last week, a new RN made the exact some mistake I had made a year before, but twice during her shift. She was agonizing over her error, as I had the year before. I jumped in and showed her how to clean it up/cover her tracks with no undue attention being drawn to it. Another experienced RN jumped in to double-check our work to make sure we did it right so that nothing would be flagged in an audit or by the pharmacy. It took about 15 minutes for all three of us to straighten it out, working together. Neither that RN nor I will ever make that mistake again.

It sounds like the OP was describing a pattern of sloppiness or worse, but sometimes you just work together to minimize the disruption and move on. We work hard and we learn from our mistakes. We are only human.

You pointed out that sometimes there are honest mistakes in the narcotic count -- and that nurses working together can figure out where the error occurred and fix the count. I have found that to be frequently true. Someone intends to pull out two codiene tabs and only grabs one, someone calls out "Bring me some Fentanyl" as their patient is thrashing in the bed and Sue runs to fetch her some Fentanyl while Sam gives her the Fentanyl he's just pulled for his patient who can obviously wait a minute or two longer. Things happen.

What I don't think you are saying is that nurses working together cover up actual discrepancies. At least, I hope you are not.

[Kooky Korky, BSN, RN]

I wonder why Pharmacy didn't catch the error on the Count Sheet.

So where do things stand now, OP?

[Kooky Korky, BSN, RN]

I wonder why Pharmacy didn't catch the error on the Count Sheet.

So where do things stand now, OP?

As already stated, if a narcotic situation is in errors, stop the Count, notify the Supervisor immediately. Your facility might require that no one leave until allowed to by Security, Pharmacy, and Nursing, everyone might have to get urine tested, personal items can probably be searched, and maybe more. This really is a very serious situation and you did the right thing by reporting, but you should report again, this time in writing and keep a copy (maybe in your work locker, with names and identifiers so you don't forget - do not violate HIPAA by removing it from work). Note who you reported to and when.

You were wrong to sign the Count sheet. And you should have made a copy of it both before she changed it and after.

IF your coworkers get ugly toward you, ask sincerely, in the spirit of truly wanting and needing to learn, how they would have handled it. What would they have done if they had come across these errors and seen the changing of the record? Would they have covered for her? Would they cover for you???