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"?
Specializes in Peds/outpatient FP,derm,allergy/private duty.
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?!
It may be an assisted living or skilled nursing facility that doesn't have 24/7 pharmacy coverage, and contracted to a local pharmacy for after-hours coverage. It's pretty common to have a 24 hour pharmacy in a local retail establishment nearby. The rx would be transferred, order and all.
It may be an assisted living or skilled nursing facility that doesn't have 24/7 pharmacy coverage, and contracted to a local pharmacy for after-hours coverage. It's pretty common to have a 24 hour pharmacy in a local retail establishment nearby. The rx would be transferred, order and all.
Interesting. Have never heard of this b4. How do they stop nursing staff, or whoever is picking up the drugs, from pilfering them? I would not have thought this was allowed anywhere.
Interesting. Have never heard of this b4. How do they stop nursing staff, or whoever is picking up the drugs, from pilfering them? I would not have thought this was allowed anywhere.
The pharmacy is locked with an alarm system. You can NEVER just go in and grab what you need. There are a few meds available in an emergency box but you can't just go grab those either--you must have a Drs order obviously. There are only about 20 meds in the lock box, things that you might routinely get ordered on a weekend for instance like and antibiotic. The other side of the pharmacy is COMPLETELY locked and there is no possible way to get in there.
It may be an assisted living or skilled nursing facility that doesn't have 24/7 pharmacy coverage, and contracted to a local pharmacy for after-hours coverage. It's pretty common to have a 24 hour pharmacy in a local retail establishment nearby. The rx would be transferred, order and all.
That's exactly what it is. Not illegal going on, I assure you. :)
I am not a mean nurse, nore do I have temper issues. I am just applauded that someone would report something they HAD NO KNOWLEDGE of. YOU can suspect somone untill cows come home, but you cannot report someone unless you know for that they are committing fraud. You suspicions may be unfounded, but yet innocent person may get into trouble. What is someone( DON) asks her about it, and she panics and gives a wrong answer?? ALL your fault.
I still say what you did was wrong and had no merit
I would question it. There could be many other explanations for it, but still...question it.
Maybe they used another OTC supply for another pt? Maybe the nurse didn't give it but forgot to circle it? Maybe they found extras or a med that was going to be wasted and just used it.
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.
Pepcid is a trade name for famotidine, an H2 blocker. For those who are not familiar with the med, it is used to treat heartburn as well as the ulceration and inflammation of esophagitis resulting from GERD. So while it is an OTC med, missing it could cause that patient to be doggone uncomfortable and delay the healing of any esophageal irritation from acid reflux.
Carolmaccass66 is absolutely right. Some nurses DO divert drugs. Some nurses DO make mistakes. Some nurses ARE sloppy and will sign off a med that they haven't given or won't look at the MAR to see if there are any changes in orders. Not all nurses divert or are sloppy---although we all do make mistakes. I've written myself up for drug errors! Sure I felt like an idiot having made the errors, but it was the right thing to do.
Again, what might seem "inconsequential" to one nurse may have great implications for the patient. The OP needs to be polite and respectful, not accuse the other nurse of doing something wrong, but she needs to report this. It is the ethical thing to do.
I am not a mean nurse, nore do I have temper issues. I am just applauded that someone would report something they HAD NO KNOWLEDGE of. YOU can suspect somone untill cows come home, but you cannot report someone unless you know for that they are committing fraud. You suspicions may be unfounded, but yet innocent person may get into trouble. What is someone( DON) asks her about it, and she panics and gives a wrong answer?? ALL your fault.
I still say what you did was wrong and had no merit
Sarah
and yet, I remember reporting a nurse one time for suspicion of diverting b/c I noticed this particular nurse chasing down the dr's in the unit telling them that their pt "needs demerol." It raised a red flag in my mind after witnessing this one time to many on a busy night shift. I reported it to my manager. Turns out after an investigation that this nurse had been diverting demerol and self injecting for God know's how long. I'm glad that I listened to my gut instinct.
Having said that, I don't report things to management such as a pepcid not being given. However, I would leave the nurse a note asking about it. Ppl, we're nurses. Cant we use nursing judgement and try to help each other?
Are you insinuating that you just pretend not to notice? Surely not....
If all was as posted,...
This was a legally documented administration of a medication by a licensed professional.
Therefore this was an acusation of both falsification as well as omission based upon the subjective analysis (detective work) of a non-qualified investigator.
Therefore, in this case most certainly; "Hear no evil, See no evil, and Speak no evil."
If an employer were to take action on me based upon such a supposition, the acuser would be liable for damages.
This was a legally documented administration of a medication by a licensed professional.
Therefore this was an acusation of both falsification as well as omission based upon the subjective analysis (detective work) of a non-qualified investigator.
Therefore, in this case most certainly; "Hear no evil, See no evil, and Speak no evil."
If an employer were to take action on me based upon such a supposition, the acuser would be liable for damages.
Wow. I'm so surprised at the widely differening opinions on this.
I guess to me, my job was to report what I observed. Then someone of a higher authority than me (DON, unit manager) is the one that investigates, talks to the other nurse involved and makes a decision.
I find it shocking that someone would tell me to "Hear no evil, See no evil, and Speak no evil." or to basically look the other way when I find a possible med error. Again, what if it was coumadin? Morphine?
I think that what this conversation has taught me is to not determine for myself what is a reportable med error and what isn't. An omission is an omission and I will be reporting as such from here on out. Thankfully in my year at the facility this is the only time its happened so its not something I'll be dealing with on a daily basis! :)
nursel56
7,122 Posts
It may be an assisted living or skilled nursing facility that doesn't have 24/7 pharmacy coverage, and contracted to a local pharmacy for after-hours coverage. It's pretty common to have a 24 hour pharmacy in a local retail establishment nearby. The rx would be transferred, order and all.