November 16, 2009

So I call for the nursing supervisor...

and ask her to come on up to my unit whenever she has a chance, no rush.  She appears pretty fast, considering that it's the end of the shift.

I tell her I discovered that I made a med error yesterday:  when I was doing my nightly check of the MAR, I noticed that I missed signing off on an entry the day before (the day I didn't do a nightly check since I had a late admission).  I was about to sign it when I figured that since it was a narcotic (not really--it was Tramadol, but we do keep it with the narcs since it's usually given with Phenobarbital), I'd check the narcotic log to see if I did give it.  And I didn't.  That was a busy night:  I'm trying to pass meds and someone's knocking on the med room door q5 minutes to ask/tell me something.  It was very distracting. 

"So what are you going to do about it," she asks. 

I hand her a completed medication variance form and incident report.

"Oh," she says.

"You need to fill out the back part," I tell her, "since I was the only nurse here that night as well as tonight."

I think she was a little shocked that I wrote myself up.  In her day job, she's a nursing instructor, and I think she was preparing to lecture me.

To be honest, the odds are that the error never would have been discovered unless they decided to audit that particular chart.  I could have signed it and let it go, and I'd be a liar if I said that never crossed my mind because it damn well did...but my conscience would have gotten to me.  And once I start down that road of not reporting errors...pretty soon I'll be falsifying documentation, diverting drugs and barking at patients, "you're crazy, just deal with it".   So I did the right thing.  

Now I'm up to 2 reported med errors, but this is the first that is 100% my fault (the other was the one due to another nurse transcribing the order wrong then altering the MAR after I gave the dose--I was the one who filed the variance/report.  The unreported one was also due to another nurse's error in transcribing, but since it helped get the patient's HTN finally under control, the charge nurse and I got a one-time order to cover it).  

"Am I going to get fired for this?" I ask...not entirely in jest.

She laughs.  "Please...if only more people here did this."

I probably won't get fired, I take it.

I don't like making the errors though...the problem is when I'm the only nurse on the floor doing both charge and meds, it can be distracting especially when everyone is coming to me because I'm the resident RN.  I think I need to set a policy that, if I'm the only nurse on the floor, unless copious amounts of blood are involved or a patient is about to go off the psychotic deep end, that I'm not to be disturbed during the med pass.  Either that, or I need to get the nursing supervisor down here to cover charge for the 20 minutes.

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