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 Nursing Practice > You Asked Us Online 

 Last modified June 20, 2006 

Responding to a Colleague's Error

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Q

I’m a nurse manager. Last night, a nurse on my unit administered the wrong medication to a client. The client had an allergic reaction and required emergency treatment. Fortunately, the client responded well. Do I need to report the nurse to the College or can I deal with this myself?

 

A

There is no mandatory requirement for managers to report individual errors or practice concerns to the College, unless the nurse’s employment is terminated or the nurse resigns due to the error or practice concern.

Whether you choose to respond with educational or disciplinary action will depend on a number of factors. To make a decision that is in the best interest of the public, you will want to consider the following.

Was the nurse’s past practice competent and safe, or did the error reflect a practice pattern. If it is the latter, what were the prior concerns and what action was taken? You may want to respond differently to situations where previous attempts were made to help the nurse address practice concerns than to situations where no previous concerns had been identified. The nurse’s response to previous practice concerns should also be considered.

Were there factors that impacted the nurse’s ability to practice safely? For example, staffing and assignment problems, fatigue and systems issues such as labeling and storage of medications can all impact the safe delivery of nursing care and contribute to errors. It is important that you identify and resolve these issues to prevent further errors from occurring.

How did the nurse handle the error? Did the nurse act to ensure the client’s well-being and limit exposure to any potential harm? This involves acknowledging that the error occurred, reporting it, and taking appropriate action such as treating/ monitoring adverse reactions.

Was the nurse able to reflect on how or why the error occurred and identify strategies to prevent a similar error? This may include identifying systems issues, as well as personal learning needs.

How was the client affected? If the client outcome was positive and the nurse demonstrated accountability for ensuring client safety both immediately and in future, there may not be a need to take any educational or disciplinary action. A very different approach may be taken if the client outcome was negative, there is a prior history of practice concerns, and the nurse did not demonstrate appropriate accountability for client safety or for her/his own practice development.

By considering all these factors when deciding how to respond, you will be better able to act in the best interest of the public, the nurse and the facility.

For more information see the Medication practice standard and the Complaint and Report Guide for Employers. Both documents are on the CNO website at www.cno.org.

 

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