writing up another LPN for med error

[luvmy2angels]

First off, let me say that I hated to have to write up another co-worker for a med error but I feel it was my job and obligation. I mean, isn't our work to protect our patients??? I say this because when I handed the med error paper to my supervisor I could tell she was a little "peeved" that I had done it. The error was nothing serious, my resident was scheduled to start a multi-vitamin and the other nurse had signed off as giving it for 3 days in a row, however when I returned to work the box was unopened and the # of pills in the box was the # that was delivered. In my opinion, even though it was just a vitamin it was still prescribed my the doctor and should have been given, signing off for ANY med that isn't actually given is a med error, or am I completely off my rocker???

[HisHands, ASN, RN]

You know better than I do what happened. My only reservation about this situation is that perhaps this patient had another bottle of MVI that was getting finished off, and you happen to be there to start the new bottle. Perhaps she couldn't find that box and borrowed from someone else. If you feel like these weren't the situation (only you know), then yes, I absolutely agree that it was a med error and should have been written up. I have written more than a few people up over blatant errors. If it's something that seems so big that nobody should have missed it (ie. not giving someone their Lovenox 80mg inj for 4 days), then I ask the other nurse about it. I would expect the same for me. Part of being a nurse is working as a team and watching out for each other. We are all human. I would expect someone to write me up if I made a mistake.

Blessings,

Crystal

[UM Review RN, ASN, RN]

Kinda makes me wonder what else she's been signing off as given when it hasn't been given, if you know what I mean. There is a proper way to chart meds that have not been given, after all.

[SuesquatchRN, BSN, RN]

I would have mentioned it to my supervisor before writing it, simply because I work with SuperNurse who is always assuming errors that aren't there.

She wrote me up last week for not giving an entire day's meds to one resident claming that I had signed off and not poured, which she "knew" because the day's date wasn't written on the cards. Well, I DO NOT sign before I pour, and I NEVER sign a whole sheet before pouring - I can see that I signed a Tylenol without thinking, but NOT the whole sheet. I don't like the assumption being made.

[TazziRN, RN]

At face value it looks like a med error, but maybe you should have either asked the nurse or talked with the supervisor and asked her to check it out first. It would be different if you knew for sure that an error had been made, but the others have made a good point: there could have been an old package to finish up first.

I said "maybe" because I can think of other possibilities: was the order a new one? If a MVT had not been ordered before, then she lied. Did she borrow from another pt's stock? Then it should have been replaced from the new box asap.

[CHATSDALE]

lateral writeups are always risky and can cause hard feelings

talking with the other nurse or talking to the supervisor and allowing her to persue the matter

however you are the patients advocate and you make your own decisions about how to fulfill this obligation

[jjjoy, LPN]

I agree that ideally the OP would first address the issue unofficially, with the nurse in question if she's/he's availabe, or with the manager - as there may be a harmless explanation. If one's managers and co-workers are approachable, then, definitely talk to them first about the issue in question.

However, we are all learning. At least the OP noticed the discrepancy and did something about it and ideally the manager should be pleased about that. Maybe a write-up wasn't yet called for, but then I think it's the manager's role to discuss with the OP how to deal with this type of situation. Not to just give a look that implies exasperation (or whatever).

I do know that some managers aren't willing to take on these kinds of 'minor' issues, either because they've already got too much on their plate or because they know the person in question is set in their ways. In such cases, instead of being open about the reason for not pursuing the issue, some managers try to make the person questioning the problem feel bad for rocking the boat. The same with colleagues who take what they see as safe shortcuts (such as not passing vitamins when pressed for time or keeping an extra stash of some meds so they don't have to wait for pharmacy) and resent being questioned and probably also fear that they won't be allowed their shortcut anymore.

[luvmy2angels]

I actually did take this to my supervisor first and she didn't know what to do about it, (she is relativley new). she said write it out and give it to dayshift to investigate, i didn't want to do that because it didn't happen on dayshift.

As far an another box being used up , it wasn't, as this was a new med order and I am the one who put the order in the computer and there were no other residents that had this med in a box on my cart.

I didn't want to write her up, this is the first time i have had to do it. This nurse works the days that I don't so I have never even met her. I do know however, that there have been complaints filed against her from others and aides that have had to stop her from giving someone somebody elses meds (they would hear her say "here 'so and so', here are your pills", and it wansn't even the correct resident. She can supposedly finish a med pass of 28 people in 45 minutes or less. I truly feel she is being careless and that is why i felt i needed to write it up and bring it to the DONs attention. If she gets careless with the wrong resident and the wrong med there could be a great deal of harm done to the resident.

It is not a nice situation to be in, but i did what i thought was right. I guess I'll see as i am getting ready to leave for work now.

Thanks you guys for all your input, I appreciate all of it!!

Have a good one, will check back when i get home from work!!

[HisHands, ASN, RN]

ok.... with all of the facts, I support and would have done the same thing.

[SuesquatchRN, BSN, RN]

ok.... with all of the facts, I support and would have done the same thing.

Yup.

45 minutes for 20 odd patients? Heck, I couldn't crush 'em that fast, let alone do it right!

[walk6miles]

I am really offended by your miserably negative way of handling what you, her coworker (not her supervisor) deem as this nurse's poor handling of medication distribution to patients. Here is my first criticism: you are one LPN writing up another LPN - why the distinction? You are a nurse; she is a nurse - if you worked with me (an RN), I would NEVER make that distinction - I don't discriminate against LPNs.

Second criticism: why didn't you sit down with this nurse and share your concerns? Instead you go off behind her back and spread more ill feelings (see your statement: "complaints filed by others..."). The whole thing with nursing is TEAM WORK.... we have had several nurses who needed a friendly hand to get into the swing of things... if you spend time supporting her instead of backstabbing her,you might find that she will trust you and ask for your help.

You even criticize your supervisor for her lack of experience. I really wouldn't want to work around someone who holds everyone else up for ridicule.

Should you have written up the error - did you speak with the nurse about the vitamin bottle and give her a chance to explain? Did you share your suspicions with her? Did you give her a chance?

We had an incident involving myself and another nurse - she was caught redhanded charting that she had given Lovenox -- and she reported to me that she had given the shot at 1500 hours; after report, she ran to Pyxis to pull out the shot and give it to the patient. I stopped her before she gave the shot; I let her know I knew what she was about to do and had her give the shot and then work with pharmacy to change the next time it was due since the long delay meant changing a scheduled medicine. She also acknowledged that had I not known, and had the drug been given as previously scheduled, it could have been a problem for the patient.

Did I write her up? No, I fixed the problem, not the blame. She is a much more careful nurse and has become one of the most reliable and helpful nurses in the unit. She explained she felt orphaned from the other nurses, she felt alone and pressured. When she and I met with the unit coordinator, instead of feeling lost, she agreed to work with us to improve her skills.

I am now working on another nurse's attitude; I am available for any help, questions, concerns. He is responding very well; most of his critics have stopped demeaning him; the unit is more peaceful and the sense of TEAM is

slowly growing.

Hey, I am no saint but, as I have gotten older and more experienced, I have found that if you maintain an open and positive attitude, you can be a positive influence on the atmosphere in your unit and the PATIENTS benefit!! Everyone benefits from team work!

[danissa, LPN, LVN]

.just curious, do you not need two staff to check drugs prior to administration?? Two trained staff have to check EVERYTHING for our babies, from Iv's to even Vits, both have to check the meds, and the name bands etc! For IV's, we check the prescribed dosage from our drug formulary prior to making them up and giving them.