writing up another LPN for med error

Published

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???

Specializes in Lie detection.

Nurses should not be writing each other up if it can be avoided.

Way too many write ups occur between staff, it's ridiculous. Try discussing things first!

I have never written another nurse up, ever. Things have happened and I have brought it to the nurse's attention, problem solved. Sometimes people are HUMAN. I know when I've brought stuff to their attention, I've pretty much always gotten a good response AND at thank you.

Writing each other up divides us. . Do you think other professions do this? I've never heard of cops writing each other up, or teachers, or engineers, or Doctors, etc, etc, etc.... Someone please correct me if I'm wrong.

Specializes in Med-Surg.

First of all nurses do not "write up each other". Only managers, charge nurses and supervisors/DON's etc. "write up" their subordinates.

We can write incident reports of med errors and it's our obligation to do so. You follow what your inner voice and conscious tells you to do in these situations. "It's only a vitamin", but skipping a patients meds is a red flag and an error that probably should be reported. Missing medications unfortunately happens from time and to and I do not report each and everyone. However, if a med was missed that many days I would consider it.

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???

I think that you should have taken the box of unopened meds and a copy of the signed MAR to the supervisor and let her handle it from there. It is her responsibility. If after that you felt that it was not taken care of by the supervisor ,then go to the supervisor's superior. But you went overboard doing it yourself, that is what the supervisor is there for. And you do have to work with the person.

Not to start a fight but how do you have time to check up on another nurse and berate her skills if you are doing your job? I know that when I work I do not have the time, energy, or ranking to check up on what everyone else is doing. MVI are stock at our facility and while it is against policy to borrow it does happen if we run out. Help to you now that you have written the colleague up because I am positive you will be looked at with a fine tooth comb whether or not you do anything wrong it's a tough environment to work in. Medication errors are bad, do the 5 rights and they might still happen once in your career but please help the nurse instead of hindering her. Just my two cents.......

When you follow a person in a shift you are going to notice things like that, especially if you work on the same cart day after day. You know your meds and cart like the back of your hand. There are nurses that do not pass their meds....we are not all "Florence Nightingales..."

Specializes in Rehab.

I'm having a hard time understanding why this poor girl is being roasted. Whether she thought this other nurse was "too fast" and "obviously" a lousy nurse is neither here nor there. The point is that this young lady sees a newly ordered med that nobody else is on, the box isn't opened, and the med is signed as given. You sure can't pull it out of thin air. If it's not available, it's not available.

And, I think the attitude that it's an "unimportant" med is lousy! I think people that consider it unimportant are people that will say other things aren't important. No need to write up that incident report. Mrs. Jones didn't hurt herself when she fell. It didn't look like she hit her head. What? She ended up having a slow bleed and died?! Hmm.... I guess I should have written that report up. No matter what med is written on that sheet, it needs to be given if you sign it out. Some people do this with creams too. It's funny how people sign out orudis gel as being applied q shift and the orudis gel was never opened.

Doesn't matter what it is... those 5 rights apply to any med from Dilantin to a multivit.

OP you do have supporters. I think you genuinely attempted to do the right thing. Maybe I would have asked the other nurse about it. Any med error I've written up, I've told the other nurse about so that she wouldn't feel blindsided. Med errors are an exceptionally big deal in my facility. They are crazy about them (which I personally think is good). 3 errors, no matter what, and you are out. Doesn't matter what it is.

Blessings and take this as a learning experience,

Crystal

Specializes in Rehab.

I don't find anything wrong with writing a med error on another nurse. That is NOT something reserved solely for mgmt in our facility.

I don't find anything wrong with writing a med error on another nurse. That is NOT something reserved solely for mgmt in our facility.

When you get your RN I guarantee you that you will look at things differently. I was an LPN for ten years, I thought at that time that I was there to police everyone;nursing assistants, other LPNs, and RNs. But it is important that we all work within our own roles it is more than enough to do. And usually more effective with the problem. By the charge nurse taking care of the incident the nurse will be be apt to stop the behavior. With the coworker submitting the report, there will be a creation of a hostile work environment between the two nurses and possiblity other nurses that work in the unit as a result. It is just better to let the supervisor do her or his job. It is not personal, it is just their job. Let them do it, that is why they are there in the title. If they cannot do their job, it is time to report them.:monkeydance:

Specializes in Geriatrics.
Not to start a fight but how do you have time to check up on another nurse and berate her skills if you are doing your job? I know that when I work I do not have the time, energy, or ranking to check up on what everyone else is doing. MVI are stock at our facility and while it is against policy to borrow it does happen if we run out. Help to you now that you have written the colleague up because I am positive you will be looked at with a fine tooth comb whether or not you do anything wrong it's a tough environment to work in. Medication errors are bad, do the 5 rights and they might still happen once in your career but please help the nurse instead of hindering her. Just my two cents.......

Well, i wouldn't consider it checking up on my co-worker. I am on the same cart all the time and therefore know what is given to my residents. I am the one who took the order off and put it in the computer so when i saw that the box was not opened I went to make sure it hadn't been dc'd. which it hadn't. It was then that I saw the other person had been signing it off as given. WHen you are on the same cart all the time it is easy to spot a potential error or mistake.

I am by no means claiming to be perfect as I have made med errors myself.

And to those who think I should have approached the nurse first, I have never even met her, we work opposite days and if i saw her on the street and passed her I wouldn't even know it.

The policy states that the person who finds the error is the one that is supposed to write it up, meaning that yes LPNs can write up the med error.

And lastly, NO we don't stock multi vitamins so there was no other place for her to get one. If she was going to give it, it was RIGHT THERE in the drawer, she simply didn't read the order.

It was investigated today and found to be that she indeed DID NOT give the med and my NM was actually glad that I had brought this to her attention.

So for those of you who wish to continue flaming me please feel free.

Specializes in Geriatrics.
When you get your RN I guarantee you that you will look at things differently. I was an LPN for ten years, I thought at that time that I was there to police everyone;nursing assistants, other LPNs, and RNs. But it is important that we all work within our own roles it is more than enough to do. And usually more effective with the problem. By the charge nurse taking care of the incident the nurse will be be apt to stop the behavior. With the coworker submitting the report, there will be a creation of a hostile work environment between the two nurses and possiblity other nurses that work in the unit as a result. It is just better to let the supervisor do her or his job. It is not personal, it is just their job. Let them do it, that is why they are there in the title. If they cannot do their job, it is time to report them.:monkeydance:

As i stated above, it is NOT my supervisor's job to write up the med error, whom ever finds it is the one to write it up. I spoke with my other supervisor tonight and she told me that i did the right thing. We are to write it up and give it to the DON and she takes care of the rest.

Specializes in Rehab.
When you get your RN I guarantee you that you will look at things differently. I was an LPN for ten years, I thought at that time that I was there to police everyone;nursing assistants, other LPNs, and RNs. But it is important that we all work within our own roles it is more than enough to do. And usually more effective with the problem. By the charge nurse taking care of the incident the nurse will be be apt to stop the behavior. With the coworker submitting the report, there will be a creation of a hostile work environment between the two nurses and possiblity other nurses that work in the unit as a result. It is just better to let the supervisor do her or his job. It is not personal, it is just their job. Let them do it, that is why they are there in the title. If they cannot do their job, it is time to report them.:monkeydance:

FYI, we have been told repeatedly by our mgmt that whomever finds it reports it. My shift supervisor has much more important things to do than write up my errors like running for the glucagen when we have a pt with a BG of 34, or making sure our new nurses are supported so they won't be the ones getting all those med errors, 2 - This other nurse should receive that write up and say, "OMG, I made a mistake... I'm so sorry... how do I fix this problem... etc." Not "I can't believe Nurse Jane wrote me up. Now I'm going to make sure to look at everything she does" 3 - I don't know how my title as a nurse has anything to do with this. If you want to create a hostile environment (in work, life, or say, on this thread), bring up someone's title like that.

Maybe that's how it is where you work. Where I work we don't run to the sup for everything. They accept the fact that we know what's going on with our pts and if something is wrong we are allowed to correct it appropriately.

Blessings,

Crystal, LPN (and charge nurse... frequent shift supervisor...)

When you get your RN I guarantee you that you will look at things differently. I was an LPN for ten years, I thought at that time that I was there to police everyone;nursing assistants, other LPNs, and RNs. But it is important that we all work within our own roles it is more than enough to do. And usually more effective with the problem. By the charge nurse taking care of the incident the nurse will be be apt to stop the behavior. With the coworker submitting the report, there will be a creation of a hostile work environment between the two nurses and possiblity other nurses that work in the unit as a result. It is just better to let the supervisor do her or his job. It is not personal, it is just their job. Let them do it, that is why they are there in the title. If they cannot do their job, it is time to report them.:monkeydance:

Well, I have my RN and I think the OP did nothing wrong. We are not there to police our coworkers but we are there to advocate for our pts. If the OP got no response from her supervisor then she was right to write it up herself. If everyone sloughed off a task because "it's not my job/place to do it" then nothing would ever get done.

Luvmy2angels, clear out your PM box!!!

+ Join the Discussion