Putting Principles before Personalities

2 Last night, while reconcilating MARs, I noted that an 8 y/o Patient had been prescribed Depakote 250 mg am/500mg pm. The PharmD had transcribed it as 250mg and 500mg am. The med had been administered for two days as a single dose. The MN Nurse who had reconciled the previous two nights MARs had allowed the order to stand as transcribed.

I contacted Pharmacy in order to gain a consensual perspective, thinking that I could have missed something, which I do sometimes. No, I hadn't and the MAR was corrected. I contacted the MD, informed him of the original order, the actual administration, and the rectification. He said, "That's fine." I let the House Suprvisor know what was going on and she reinforced that I should also fill out a Med Variance form.

Tonight, I'm working with the MN Nurse who allowed the order to stand as transcribed. I informed her in private of the variance at the beginning of the shift. She said, "I don't do that, but you gotta do what you gotta do."

I sensed she was upset with the occurence. After things had settled down, I approached her with my my observation. Basically, what transpired during the conversation was: She accused me of selectively following protocol, attempted to bring heresay into the conversation, accused me of acting due to personal reasons, and interrupted twice while I was speaking. I told her that no good was coming from this conversation and ended it.

I'm O.K. with my actions in this situation. Had I acted totally out of emotions, I might have been able to just shine this situation on. However, I am a Nurse first and believe I acted according to my beliefs and principles.

Too bad we can't be Peers and friendly acquaitances.

Oh well. What are you gonna do, but live and let live?

Thanks for allowing me to process this emotionally-charged situation.

Dave Last edit by Davey Do on Dec 13, '10
Dave--I was in a situation in the past in which I would have given anything if the other nurse had communicated directly to me what they had done. That communication would have been a tremendous help (thankfully, no errors were involved). Instead, I didn't know until I was leaving that there had ever been any issue, and left the unit feeling as though my whole time there had been a farce, and feeling that my integrity and professionallism had taken a beating, leaving a less than positive reputation behind. It would have been so much better if I had been able to resolve things professionally before that time. Anyway...You did the right thing---patient first, and you dealt with this professionally, I believe. It sounds as though the other nurse was embarrassed to be in error and was dealing with that in an immature manner.I hate it when adults are more childish in behavior than a child!Hang in there and keep up the good nursing!

When a nurse (or anyone else, really) is confronted with an error she's made, the natural reaction for many is to become defensive, or to try to blame someone else, or to minimize the error. It takes some courage to accept the situation and own up to it. Not too long ago, I made a med error- no one was harmed, thankfully- and the next nurse discovered the error. She properly wrote me up. I did not take offense to the write up; I deserved it and I didn't think for a minute she wrote me up for personal reasons. Even if she HAD done it for personal reasons, I had to accept that an error occurred, I was responsible, and I deserved the writeup. When talking to my boss, I took full responsibility for the error and added that I would use this as a lesson in the future.I was expecting to get a bad eval because of my mistake. To my surprise, that med error (or rather, my forthrightness in taking responsibility for it) gave me gold stars on my yearly eval! My bosses were impressed that I was honest, didn't try to "get out of it", and used it as a way to improve my practice. They said that my willingness to admit my mistakes makes me very trustworthy.I can see how having less-supportive bosses would cause nurses to tend to hide/protest errors. Or perhaps this nurse, unbeknownst to you, has a pattern of similar mistakes and is already under scrutiny. Maybe she's a perfectionist who can't bear to think she's as human as the rest of us. In any case, you know you did the right thing. You really couldn't do otherwise without sacrificing your own integrity, and of course you have a duty to your patients to ensure mistakes are kept at a minimum. This was a med error plain and simple and even though it didn't harm the patient it must be written up. Remember that a major reason for filing incident reports is so process problems can be identified; if you can't tell where or why mistakes happen, you can't fix it to make errors less likely. Your colleague's reaction is unfortunate, but you are not responsible for her feelings: she is. Maybe after she calms down a while you could approach her and explain you were not targeting her personally and that you really do admire/respect her (if this is true). That would be a nice thing to do, but again, she's a grownup and her feelings are not within your control.

You definitely did the right thing, patient comes first.Here's one for you.I got a med error last week for neglecting to give an Ativan. Ok, no problem, I accepted my mistake and moved on.However, the nurse who was on the cart before me was initially contacted about the error. She denied it since she had gotten off work early that day. She couldn't drop the fact that she'd been contacted about it. She had to go on and on about it not just to me, but to another co-worker and then to the ADON. Why? She didn't get the write up, I did. I signed the paperwork and moved on with my life.Some people just can't move on.

While I believe you were correct in documenting the error, and it was professional and proactive of you to speak personally with the nurse involved ... I'm not sure what else you were looking for from her that made you go back and speak with her a second time and have the more unpleasant conversation. Of course she was upset - she's just been told she made a med error. You both handled it professionally the first time - what was the value or purpose in reopening the conversation?

To the OP-you did the right thing! You talked to the nurse-before she heard it from your manager or anyone else. She was defensive and nasty because she knew she was wrong.

Quote from AltraWhile I believe you were correct in documenting the error, and it was professional and proactive of you to speak personally with the nurse involved ... I'm not sure what else you were looking for from her that made you go back and speak with her a second time and have the more unpleasant conversation. Of course she was upset - she's just been told she made a med error. You both handled it professionally the first time - what was the value or purpose in reopening the conversation?

Quote from Altra ... I'm not sure what else you were looking for from her that made you go back and speak with her a second time and have the more unpleasant conversation. Of course she was upset - she's just been told she made a med error. You both handled it professionally the first time - what was the value or purpose in reopening the conversation?

Quote from TweetyI agree with the above. You did the right thing, but going back a second time might have been like rubbing salt in the wounds. You didn't need to justify yourself to this nurse or win her over.

Having recently been blindsided by a performance appraisal, I think it was good of the OP to go to the nurse involved and explain what he'd found.... it was a confusing order, and should have been clarified, or written better to make it easier for the pharmacy to put on the MAR.I am on the fence with how to react when a med error is pointed out to me, however. I find that the less that you say either way the better, defensiveness is never good, but sometimes in admitting fault your words may be used against you later. And while the employer always SAYS that incident reports are for quality control, alot of nurses do use them to attack another nurse, or will overlook an error if it is a friend.I was recently accused and kept from getting a position due to so called "errors" and ommissions that every member of staff is sometimes guilty of, ie: forgetting to sign for a med (sometimes I come in and NOTHING has been signed for the entire day, or an entire med pass), or forgetting to give a irregularly scheduled med because it was not clearly documented or passed on by the shift before. Being a prn worker, it is sometimes difficult to walk onto a unit where you haven't worked for weeks and just slide in and know what's going on. One of my former managers said that if the system is not set up so that any nurse can walk in and be able to perform the shift duties without forgetting or not knowing about something, that is a sign that the system should be set up better. But sometimes errors are just used to justify a decision.What I can't figure out is, why when a position comes up and is awarded and grieved, does the management and HR person not find ways to make the successful applicant look BETTER, instead of finding a way to ATTACK and CRITICIZE the unsuccessful one? Just a shift of paradigm from Positive to Negative I guess.

I can understand trying a second time to explain and smooth things over.

Quote from MulanI can understand trying a second time to explain and smooth things over.

I thank you all for your support and your perspectives.The problem-solving process was a systematically logical action. The emotional variable came into play when I made a decision to attempt to process the situation with my Peer. I wanted to treat the other Nurse as I would have wanted to be treated had the tables been turned. And those are the words that I used to begin the conversation. I wanted to let the other Nurse know that no personal motives were involved. When the other Nurse became defensive, I knew that the intent of my actions were not being recieved. So, I ended the communication before it esculated into something which neither of us could control. The night progressed without incident and we treated each other civilly. Some situations involving errors can be easily overlooked and need not be dealt with an intervention such as this. One such example would have been if the Patient had not recieved the medication. That would have merely entailed the correction of the transcription and notifcation of involved parties. When the Patient had recieved the dose that was not as the MD had prescribed, the invasive reporting process needed to take place.Primarily, I deal with the Adult Psychiatric population. That is my comfort zone. However, when I am assigned to the Children's Psychiatric Unit, I tend to be hypervigil.I was aware that Depakote can cause hepatic dysfunction such as agranulocytosis in adults. This is one reason liver function tests and valproic acid levels are monitored during this type of treatment. In researching the untoward effects of Depakote, I also found that hemorrhagic pancreatitis can result with a rapid progression from the initial symptoms to death.All the literature I studied noted for the treatment of manic episodes associated with Bipolar D/O, the Depakote doses are divided into two or more smaller doses per day. This information reinforced my action to contact the MD and follow through accordingly.So, as I said in my initial post, I am comfortable with my handling of the situation.Once again, I want to thank each and every one of you for your input.Dave