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"?
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.
Specializes in Trauma Surgery, Nursing Management.
Hmmm...further investigation is definitely warranted here. I think that you did the right thing. And I totally agree that if a med is ordered, no matter what it is, it should be given as ordered. I wonder what the nurse who documented that they gave it has to say? It would be interesting for you to fill us in on your findings.
I think it's good to follow up. If I were in this situation, I might have asked the nurse who signed off that she gave it where she got the pepcid from, since the pills in the box you gave don't account for her doses. It would be good to know in case there is another supply somewhere else, like if the patient has their own supply or if a family member brings it...you can go about it without coming off as accusatory.
I agree about leaving a note AND reporting only the facts without any accusation. Not only is this the right thing to do, but it protects YOU. Since there was only one pill missing, the other nurse could just as easily accuse YOU of not giving the med that you signed off on. Who is to say which one of you gave it and which one didn't??? At least you have attempted to CYA by documenting the fact that you know you gave the med, but can't confirm that the other nurse gave it.
I think you did the right thing. Today Pepcid, tomorrow Morphine?
We get so focused on "its only.." or "well, yes I made a mistake but no one was hurt" that we forget that its learning from these little mistakes that prevent us from making the big ones that do cause harm.
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!
Yes I would report It. It is an ordered med. and the pt. I'm sure needed it. No med. is Just " ".
I see this less as "reporting someone" than as investigating what happened. Sure it's just Pepcid, the patient might not have been harmed by a few missed doses. However, there is documentation that something was given. My concern would be that the weekend nurse may have made an error and given something that wasn't Pepcid. I wouldn't just shrug it off, either.
If you have to ask if you should have reported it then you should have reported it. It's your responsibility to report any kind of errors that you observe. Yes it may only be "pepsid" but it is a MD order and a Nurse signed off that she gave it. You did the right thing. Don't feel guilty about doing the right thing. You would feel more guilty if something happened and you didn't report an error. Trust me it's better to report than not, always! Especially about med errors.
Sorry, you lost me when you said you get hospital DRUGS from a local pharamcy, because your facility pharmacy was closed? In Australia this would be highly illegal, and definitely not allowed. How do you get away with doing this?
Any drug error (withheld, not given, wrong calculation) MUST be reported. Don't feel guilty. It's your license on the line, plus the person who is responsible needs to be re-educated. Also you say it's just Pepcid (unsure what that is over here), but what if it had been Warfarin/Coumadin that wasn't given? Medications not given can have serious, potential side effects. Also what if it was morphine or pethedine that had been signed for and the patient said she didn't get it? Same scenario: druggies and drug traffickers (many who can be nurses) are very sneaky at hiding drugs or making up stories to hide their drug habit, and they can get very inventive. That is why we have reporting mechanisms in place - it is also to do with occupational health and safety for you, the facility and the patient.
And before my post either gets deleted or I have a million people emailing me, no I am NOT saying that all nurses are druggies and/or drug traffickers. Please do not take what I have said out of context, or get too hysterical about it!
I would do IR for med err. I did several in the past. I did not mentioned the name. Just basically said :" I administered the first tablet on.... date" and to day is the 4th day but the last 2 pills were not be given to resident according to the remained box"
Follow up with an email to manager, and progress noted if resident had any side effects, any problems. That's all
To the OP: It would have been courteous to ask the nurse in question before going to management, but, if that nurse was not immediately available, I think you were correct in pointing out a potential error to management. Even if nothing was done incorrectly, or , even if a mistake was made accidentally, management (hopefully) can take steps to prevent it from happening in the future.
Medical professionals of all stripes do shady **** every day. Unlike Sarah who thinks we should keep our mouths shut and turn a blind eye, we only better our profession by rooting out and purging from our ranks the stupid and unscrupulous.
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IowaLPN
26 Posts
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.