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Discussion

Would you have reported this med error?

Ok, so here's what happened.

I worked last Friday and we had a new admit to our skilled unit. Our facility pharmacy was closed so we had to get a few meds from a local pharmacy. One of them was Pepcid 10 mg to be given daily at 2000.

It was a brand new box which I opened to give the first dose on Friday night. I was off the weekend. On Monday night I went to give her 2000 meds including the Pepcid. When I got into the box, only one pill had been popped which would have been the one I gave on Friday night. I checked the MAR--the nurse from the weekend had signed off that she gave it. I checked the nurses notes from the weekend to see if it had been held for any reason and couldn't find anything leaving me to believe that an error was made.

I went ahead and reported it but now I'm feeling guilty. Part of me keeps saying, "Oh, it was just Pepcid, what's the big deal??" This is the first time I've had to report a co-worker for a med error. Would you have done the same? Or--be honest!--have there ever been small errors like that that you have "overlooked"?

Thanks for your input!

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    • Featured Replies

    Is it possible that they took the Pepcid out of contingency?

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    No, I would not have reported that. You weren't there, she signed it off, which legally means that she gave it. You cannot prove that she didn't give it, or that she is falsifying documentation. I would have just let that one go.

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    I agree with you grandmawrinkle, just because you were not there you do not know if this other nurse did not give the medication. Pepcid is an OT medication and it could of easily been in the hands of a family member, or perhaps a dose in the cassette that you didn't see.

    So I would not report it.

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    No, I would not have reported that. You weren't there, she signed it off, which legally means that she gave it. You cannot prove that she didn't give it, or that she is falsifying documentation. I would have just let that one go.

    I agree. I've suspected similar things when meds should have run out while I was off but didn't. But if the nurse documented that they gave it, it's just suspicion on your part.

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    I would have left the nurse a note and asked if she had given the drug. While you can't prove she didn't give it, I have to wonder if the drug was missed and she marked it off on the MAR as having given it but didn't.

    Even though this is an OTC medication, I would follow through because if it wasn't given, it is an error.

    It is easy to miss a new med in the MAR but there are, unfortunately, nurses who don't look and who will just chart that they've given a med when they haven't.

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    I agree with Moogie. If people aren't going to follow through because "its just a pepcid" what next? For me its a slippery slope. Would you not make a note if the family brought in grandma's roxanol from home and was giving it to her? A med error is a med error regardless of the med.

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    I agree that it's a slippery slope and I think that I would have reported it.

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    I would have reported, but only the facts you knew. Your statement above would be fine. You're not accusing anybody of anything. Sooner or later the pills might need to be accounted for. Maybe they were given from somebody elses supply, maybe they were missed. Protect yourself, even if you just mention it verbally to the DON. If you don't report it and somebody else has to explain, you can bet your last kahuna nobody's going to take the blame if they can pin it on you. It's really irrelevant what the pill is. You're reporting a possible error in the process.:twocents:

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    • Guides

    I don't know if you have a paper MAR, but we do - I've noticed some of the nurses initial a med before they give it to save time, then if it isn't given for some reason they will forget to circle it, leading to a lot of confusion as we work in homes and many times aren't able to give face to face report.

    I agree with Moogie's plan- leave a note, but not treat the omission of an OTC drug any diffeently than any other. It used to be that a report like that would not be seen as punitive. Though I've never experienced it myself, I've read a lot of posts from people who were fired for one med error.

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    • Experts
    I would have left the nurse a note and asked if she had given the drug. While you can't prove she didn't give it, I have to wonder if the drug was missed and she marked it off on the MAR as having given it but didn't.

    Agreed. You weren't there so you don't know what happened: it's possible she could have obtained the medication from another source such as the reopened pharmacy, discharged patient, floor stock, etc. I also would have left a non-accusatory note (the "the pill count seems off, just wanted to confirm you gave the med" type of note, not a "I know you didn't give this med!" type) for the other nurse and seen what she said.

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    i would have not reported it. what if she borrowed it from another patient or if she got it from the pyxis? i know we are not supposed to borrow but for pepcid i "think" i will if i cannot find the one for the patient and replace it back afterwards. just my 2cents.

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    • Author

    We don't have a pyxis so she would not have gotten it out of there.

    The pharmacy is closed from Fri afternoon until monday morning so she wouldn't have gotten it from the pharmacy.

    Interesting replies! I"m wondering if people would feel differently about reporting it if it wasn't a drug that is avail OTC? Pepcid wasn't always OTC....why is it so different now?

    I guess what is done is done and we'll see what happens. Thanks for the replies.

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