Top 10 reasons we get fired!-Medication Errors - page 3

by madwife2002 Asst. Admin

17,803 Views | 32 Comments

Number 5 in my series of Articles about the top ten things to get fired, discusses medication errors. Making mistakes in health care tends to be frowned upon more than any other career, the general public simply do not... Read More


  1. 1
    Quote from Ruby Vee
    I think management recognized that everyone makes mistakes. And these nurses handled the mistakes the right way -- the moment they realized they'd made a mistake, they self reported and then set about attempting to mitigate the damage to a patient. They didn't try to hide the mistake, and they were smart enough to realize that they'd MADE a mistake. These weren't nurses who made mistake after mistake, never learning from them. THOSE are the dangerous nurses.

    And the "wonder what they had to do to keep their jobs . . . . hmmmm." was just nasty.
    A nurse gave a patient 10 Digoxin tablets....this is waaaay beyond an error that could happen to anyone. This is an egregiously stupid error and I would never reward that stupidity with a promotion to management. P.S. You have a dirty mind. I wasn't thinking dirty - just imagining the person as becoming a tool.
    Last edit by subee on Jan 29 : Reason: misspelling
    PatchycatRN likes this.
  2. 4
    Quote from subee
    A nurse gave a patient 10 Digoxin tablets....this is waaaay beyond an error that could happen to anyone. This is an egregiously stupid error and I would never reward that stupidity with a promotion to management. P.S. You have a dirty mind. I wasn't thinking dirty - just imagining the person as becoming a tool.
    Worse than that, she injected 10 vials of digoxin. BUT she paid. She was devastated. The hospital moved her to a less acute patient care area where she worked for several years, becoming a preceptor and charge nurse. She headed a hospital wide committee and wrote articles for publication. After several years, she moved back into ICU and excelled as a nurse, obviously having learned her lesson about how many unit doses makes a bad idea. And after a few years in ICU as an excellent nurse, she was promoted to management. She wasn't a stupid woman, she just made one horrific mistake on her very first day off orientation. I had a lot of respect for the way she handled that medication error and with the way she handled people who were determined not to let her forget it. She was a class act all the way.
    LadyFree28, jtmarcy12, hope3456, and 1 other like this.
  3. 1
    Ruby: You're right. She does sound like a class act. It brought back awful, smelly memories of a student (over 30 years ago) who boiled a patients urine to make it a "sterile" specimen. I remember thinking that I could never, ever actually hire this person if she came looking for a job. Thanks for the long view.
    montinurse likes this.
  4. 2
    Good article. However, dismissal of RNs in regards to self reporting or non-self reporting medical errors directly impacts retention and/or recruitment. A plan should be developed to better address medical errors within health care.
    LadyFree28 and madwife2002 like this.
  5. 0
    Quote from DoGoodThenGo
    Has been almost three years and is still my *favourite* (if that is the proper word) example of a medication error and the actions that followed that took the gold for running, standing and jumping. Nurse's suicide highlights twin tragedies of errors - Health - Health care | NBC News We shall never know the full story behind the situation surrounding nurse Kimberly Hiatt. But that a well seasoned nurse with nearly a quarter century of experience under her belt could been treated so badly by her hospital, and apparently the state BON and or everyone else in the profession in that area speaks volumes. Even worse that this same experienced nurse chose to end her life rather than deal with what she saw as the real prospect of being never able to practice again also speaks volumes.
    I think of her often. She self reported - otherwise probably no one would have known.
  6. 1
    Quote from subee
    Ruby: You're right. She does sound like a class act. It brought back awful, smelly memories of a student (over 30 years ago) who boiled a patients urine to make it a "sterile" specimen. I remember thinking that I could never, ever actually hire this person if she came looking for a job. Thanks for the long view.
    Boiled a patient's urine? It boggles the mind!
    jtmarcy12 likes this.
  7. 0
    How is it possible that a different person got the wrong blood tranfusion when 2 nurses MUST verify the tranfusion? I'm sorry I am at a lost to even try and guess how that can happen when each nurse must check the arm band against the blood they are holding in their hand, then have the patient ( if alert) to state their name, then each nurse verify the information on the blood against the doctor's order, they sign off again stating the name of the patient and the blood to be transfused, then you take vital signs, I monitor for the next 15 minutes for any S&S of any untoward effects, if the facility is not doing even some of this something is wrong.
  8. 2
    Quote from jtmarcy12
    How is it possible that a different person got the wrong blood tranfusion when 2 nurses MUST verify the tranfusion? I'm sorry I am at a lost to even try and guess how that can happen when each nurse must check the arm band against the blood they are holding in their hand, then have the patient ( if alert) to state their name, then each nurse verify the information on the blood against the doctor's order, they sign off again stating the name of the patient and the blood to be transfused, then you take vital signs, I monitor for the next 15 minutes for any S&S of any untoward effects, if the facility is not doing even some of this something is wrong.
    It was a CVICU, where many blood products are given every shift. Folks (some folks, anyway) seem to get a little lackadaisical toward correct procedures when you have 6 units of RBCs and 6 units of FFP to be given in an hour. This particular nurse, who I'll call Moe, asked me to check products with him.

    "OK," I said, and started for the room.

    "Oh, no," he replied, and held out the patient's addressograph plate. "We can check it out here."

    Even though I was brand new to the facility, I refused to check blood in the hallway with an addressograph plate. Moe got angry, and collared another new nurse, who readily agreed to check blood in the hallway. And then Moe put the addressograph plate away, walked into the wrong patient's room and hung the blood. I can only assume that the second incident happened much the same way.
    LadyFree28 and jtmarcy12 like this.
  9. 3
    Realism: Every nurse has made a medication error. It is up to that individual to admit error. I think ego and lack of respect for others is blatant in our "profession."

    Realism: Nurses lie in their documentation. If our documentation was accurate to the times medications were actually given, management would have to make changes either through decreased workload, quiet time for medication pass, or increased time for medication pass.

    Realism: We try to please others departments such as pt/ot, medicine, to look better. We do ourselves a disservice. The time we spend with the patient is valuable to the patient. If pt wants to work with the patient, and you are passing meds, they have to wait. Everyone pushes the nurse out of the room, well our work is equally important as well.
    hope3456, jtmarcy12, and madwife2002 like this.
  10. 0
    Interesting Hmmmm. Don't know if I want to repeat that one


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