Nursing incident reports

[TommysDad]

Well, Tommy has been home for three days, and we have already had a medication error. Fortunately, it was Mylacon, which poisen control indicated that you could not hurt hime with it if you tried. Obviously, since this could have been much more serious, we want an incident report on file. The agency is indicating that we are unable to receive a copy of the report. We feel they are giving us a line, what has everyone's experience with this? Without a copy, how do we know appropriate action is taken? We liked the nurse, but you cannot mess with someones meds like that!

[Kate]

I would guess that you should be able to get one. Also, they are to send one to your doctor--so maybe if they refuse, you can get a copy from the clinic. They are to do this because they HAVE to go by Dr.'s orders and if they don't then they can get into trouble. We've had a couple written up but have not gotten copies of them...and it does make you wonder if it got done. I don't know the specifics though, if they have to give you one or not...I'd guess if you request a copy-they need to give you one. Or like I said get it through your doctor. Sorry you had the error to begin with...it's frustrating I know. We've have 2 med errors and now I write down on paper for that specific nurse what she is to give and when and she isn't to give anything other than what is on the paper...unless it's tylenol. I really try to give as many of the meds as I can just so I know it is done right. But sometimes it just isn't possible.

[Jordansmom]

If you guys are on the medicaid waiver you probably have a dscc coordinator. Now I don't know if this is something that person would be called for but, the coordinator Jordan has, I would be able to call and ask questions about it. Whenever I am unsure of policy and what not I ask her, but I got super lucky & have an awesome coordinator. hope you do to. I would think you are entitled to anything of Tommy's you just may have to sign a hippa release. IMO, med errors are a big one. Good luck!
Cathy

[WeAdoptKids]

It is my understanding that due to privacy laws, unless this went to an open trial of sorts, you do not have the right to know what happens. Now I am sure there are others here that know more about that.

You do however have a right to a copy of the report you filed, ask that the nurse be removed off the case and get a new nurse. You can also file a report with the medical board of nursing. Even though the med may not have been an issue this time, what happens the next time?

Just happy it wasn't anything more serious.

Hugs,
Roberta

[Livi's_mama]

Are you able to draw the meds up yourself? I know some agencies don't allow it.

I've never been one to even leave the meds in Nurse's reach. I draw them up then put them in a zip lock baggie with the appropriate time listed on it. I did the same for nebs when she was on them.

[cbissell]

I'm not sure if medication error forms are handled differently from facility to facility or if there are any state regulations that cover this. But I do know that at the places I've worked, a medication error report is a record for the agency, not for the patients records. Since it's not part of your son's record, I don't think they have to give you a copy.

Also, the doctor does not usually get a copy. The error just needs to be reported to the doctor and I'm not even sure this is an error that needs to be reported, although they probably did call just to cover themselves.

Someone mentioned calling the board of nursing. While you do have that right, this is not a situation where I would notify the board, you could scare other nurses away from your case. This is a minor issue, true it *could* have been worse, but do keep this in proper perspective.

Originally Posted by Livi's_mama

Are you able to draw the meds up yourself? I know some agencies don't allow it.

I've never been one to even leave the meds in Nurse's reach. I draw them up then put them in a zip lock baggie with the appropriate time listed on it. I did the same for nebs when she was on them.

Do you mean that you prepare the meds and the nurse gives them? From a nursing perspective, this is a BIG no no. Any nurse who would give medications drawn up by someone else is crazy. This would be worse than a medication error IMHO. But no reason why a parent can't prepare and give the meds in home care.

If you are available when the nurse gives the meds, you could ask her to let you double check the doses before she gives them. It's always a good idea to have two people check, especially for dangerous medications.

Otherwise, just remind nurses to read and read carefully, and follow the "5 Rights": right drug; right patient; right dose; right route; and the right time.

[Alex's mom]

Originally Posted by cbissell

Do you mean that you prepare the meds and the nurse gives them? From a nursing perspective, this is a BIG no no. Any nurse who would give medications drawn up by someone else is crazy. This would be worse than a medication error IMHO. But no reason why a parent can't prepare and give the meds in home care.

Interesting, very seldom do any of the nurses that we have draw up their own meds. I generally draw meds up once or twice a week. They all use the meds that I prepare. (I have 4 different nurses right now) When Alex first came home she was on 3 different seizure meds and I was a little worried about med errors. That being said, there were a few days that she was receiving double the amount of her reflux meds. There was no report filed, it was not noted on her chart. The nurse who made the error brought it to my attention. It was an honest mistake but it is scary how easy it can happen - and if the mistake was made w/one of her seizure meds - then we would have been contacting the dr.

[TommysDad]

We certainly do not want to blow this out of proportion, however, we do not want it downplayed either. This nurse clearly deviated from the prescriptions, not once, but twice in a shift, and if it were not for mother's intuition, we probably would not have known about either. Of course, for all we know, the wrong dose was given at midnight and he was just covering saying he did not give it. Mom was sleeping on the couch in the room with Tommy and asked that he verify the meds with her, and he said that she was sleeping and did not want to wake her up. You have a good point about not wanting to scare away nurses.

Even more disturbing was the way that this was handled. I know the nurse was upset, but while we are fumbling trying to call the hospital, poison control, and our doctor, he was just standing there saying that it said 20mg so he calculated it out to be 1.5ml. Granted, it was an overkill, but at least me, being woken up at 6:00am from a much needed deep sleep, thought to pull the contents from his stomach from his G-Tube, as opposed to him standing there making no suggestions as to what to do, not even call the doctor or poison control.

This nurse was also a last minute switch that did not attend the hospital orientation, and who was not going to have any overlapping time with the first nurse. We have had several last minute changes in the schedule, including one nurse that they begged to extend her shift. And, to top it off for our first three days home, we sat and watched a nurse sleep for 20 minutes last night.

[cbissell]

An isolated medication error is one thing, but incompetence is another. You are correct not to tolerate incompetence. Sorry to say this is way too common in home care. The nursing shortage plus not-so-good nurses going into home care is a major problem. You probably already know this from reading the boards. Hang in there, it's tough at first getting to know a bunch of new nurses, but hopefully you can weed through the bad and get some good and consistent nurses that you can trust.

[cbissell]

Originally Posted by Alex's mom

Interesting, very seldom do any of the nurses that we have draw up their own meds.

WOW, any of the other nurses here surprised by this?