Top 10 Reasons We Get Fired!- Medication Errors

[flashpoint]

LPNs / LVNs also make medication errors.

[madwife2002, BSN, RN]

Yes they do, edited to use the word nurse

[Ruby Vee, BSN]

We are only human, and humans make mistakes, this is not taken into consideration when you make a mistake in the hospital. Upper management will act swiftly.

Nurses do get terminated quickly when mistakes happen, especially when a death occurs. It is the first response by management and the legal department of the hospital. At times the error is investigated, with the RN in question being suspended-normally without pay.

Times are changing, with Hospitals encouraging staff to report near misses and errors, with the aim to prevent medication errors

It has not been my experience that nurses are terminated quickly when mistakes happen, especially when a death occurs. Nor has it been the first response by management and the legal department of the hospital. On each of the several instances I have witnessed a fatal medication error, the nurse was counseled by management and in two instances found a job in a less acute area of the hospital. (In one of those instances, the nurse involved worked in the SICU step-down for two years and was welcomed back to the ICU with open arms. She became an assistant nurse manager, then a manager.)

One night, a new nurse on her first day off orientation gave 5 mg. of digoxin to a patient with predictable results. Even if you DIDN'T know that the correct dose of digoxin is 0.125 to 0.5 mg, what would possess you to open TEN vials of medication for ONE dose? She's the nurse who eventually became a manager. By all accounts, she's a very good manager. The nurse who gave Mrs. Roberts' blood transfusion to Mrs. Thomas is also still employed . . . and about five years later gave Mr. Charles' transfusion to Mr. Gregory. Again -- still employed even though he made the exact same fatal error a second time.

I have seen nurses put on administrative leave while a drug error is investigated -- albeit WITH pay. I'm not saying that your scenerio of immediate leave without pay or termination doesn't happen -- it's just that in 35 years, I've never seen nor heard of it happening. One of my former managers explained that Risk Management views such as an admission of wrongdoing, which they'd like to avoid if possible.

[madwife2002, BSN, RN]

It has not been my experience that nurses are terminated quickly when mistakes happen, especially when a death occurs. Nor has it been the first response by management and the legal department of the hospital. On each of the several instances I have witnessed a fatal medication error, the nurse was counseled by management and in two instances found a job in a less acute area of the hospital. (In one of those instances, the nurse involved worked in the SICU step-down for two years and was welcomed back to the ICU with open arms. She became an assistant nurse manager, then a manager.)

One night, a new nurse on her first day off orientation gave 5 mg. of digoxin to a patient with predictable results. Even if you DIDN'T know that the correct dose of digoxin is 0.125 to 0.5 mg, what would possess you to open TEN vials of medication for ONE dose? She's the nurse who eventually became a manager. By all accounts, she's a very good manager. The nurse who gave Mrs. Roberts' blood transfusion to Mrs. Thomas is also still employed . . . and about five years later gave Mr. Charles' transfusion to Mr. Gregory. Again -- still employed even though he made the exact same fatal error a second time.

I have seen nurses put on administrative leave while a drug error is investigated -- albeit WITH pay. I'm not saying that your scenerio of immediate leave without pay or termination doesn't happen -- it's just that in 35 years, I've never seen nor heard of it happening. One of my former managers explained that Risk Management views such as an admission of wrongdoing, which they'd like to avoid if possible.

Then Ruby you are most fortunate :-)

Research -Kimberley Hiatt

I am a registered nurse and was recently terminated by my hospital employer for making a medication error. I self reported the error, informed doctor supervisor,and patient immediately. There was no harm to the patient, he was monitored for possible side effects. I have a 35 year nursing history with no errors or disciplinary occurrences.

OK: nurse terminated for medication error: court ordered unemployment benefits for RN. - Free Online Library

I have witnessed Nurses being terminated for med errors and I have witnessed places which give education!

It happens and it may be due to multiple errors and the medication error could have been the final straw.

[subee, MSN, CRNA]

It has not been my experience that nurses are terminated quickly when mistakes happen, especially when a death occurs. Nor has it been the first response by management and the legal department of the hospital. On each of the several instances I have witnessed a fatal medication error, the nurse was counseled by management and in two instances found a job in a less acute area of the hospital. (In one of those instances, the nurse involved worked in the SICU step-down for two years and was welcomed back to the ICU with open arms. She became an assistant nurse manager, then a manager.)

One night, a new nurse on her first day off orientation gave 5 mg. of digoxin to a patient with predictable results. Even if you DIDN'T know that the correct dose of digoxin is 0.125 to 0.5 mg, what would possess you to open TEN vials of medication for ONE dose? She's the nurse who eventually became a manager. By all accounts, she's a very good manager. The nurse who gave Mrs. Roberts' blood transfusion to Mrs. Thomas is also still employed . . . and about five years later gave Mr. Charles' transfusion to Mr. Gregory. Again -- still employed even though he made the exact same fatal error a second time.

I have seen nurses put on administrative leave while a drug error is investigated -- albeit WITH pay. I'm not saying that your scenerio of immediate leave without pay or termination doesn't happen -- it's just that in 35 years, I've never seen nor heard of it happening. One of my former managers explained that Risk Management views such as an admission of wrongdoing, which they'd like to avoid if possible.

What is management's interest in keeping thoroughly dangerous (and the dig. incident - just down and stupid) nurses on staff? Wonder what they had to do to keep their jobs....hmmmm.

[Ruby Vee, BSN]

What is management's interest in keeping thoroughly dangerous (and the dig. incident - just down and stupid) nurses on staff? Wonder what they had to do to keep their jobs....hmmmm.

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.

[NRSKarenRN, BSN, RN]

From the Institute for Safe Medication Practices

FREQUENTLY ASKED QUESTIONS (Faq)

What is a medication error?

A medication error is “any error occurring in the medication use process.”

The National Coordinating Council for Medication Error and Prevention has approved the following as its working definition of medication error:

"... any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems including: prescribing; order communication; product labeling, packaging and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use."

Won’t medication errors be prevented if nurses just follow the “Five Rights?”

Many nurses during their training have learned about the “five rights” of medication use: the right patient, drug, time, dose and route.

However, the “five rights” focus on the nurse’s individual performance and does not reflect that responsibility for safe medication use lies with multiple individuals. Although the “five rights” serve as a useful check before administering medications, there are many other contributing factors to a staff member’s failure to accurately verify the “five rights,” despite their best efforts. For more detailed information, see the following articles.

• “Nurses’ rights regarding safe medication administration” ISMP Medication Safety Alert!® Nurse Advise-ERR July 2007
  
• The five rights: A destination without a map ISMP Medication Safety Alert!® Jan. 25, 2007
  
• “The five rights cannot stand alone” ISMP Medication Safety Alert!® Nurse Advise-ERR November 2004
  
• The "five rights" ISMP Medication Safety Alert!® April 7, 1999
  

Wrong-Patient Medication Errors: An Analysis of Event Reports in Pennsylvania and Strategies for Prevention

Description: While events reported to the Pennsylvania Patient Safety Authority suggest that these errors occurred most often during administration and transcription, implementing safety strategies at all nodes of the medication-use process can help to ensure that the correct patient receives the correct medication.

Publication Date: 06-03-2013

During the period of July 1, 2011, through December 31, 2011, 813 wrong-patient medication errors were reported to the Pennsylvania Patient Safety Authority. These reports were analyzed to classify the events by node, related processes, possible causes, and contributing factors and to detect trends and noteworthy cases. Errors most often occurred during transcribing (38.3%, n = 311) and administration (43.4%, n = 353) and least during dispensing (5.2%, n = 42). Anti-infectives, opioids, and anticoagulants were the most common types of medications associated with wrong-patient events. While multiple factors may have contributed to each event, the most common were two patients being prescribed the same medication, improper verification of patient identification, and similar room numbers. Important risk reduction strategies include ensuring proper storage of medications and patient-specific documents, utilizing healthcare technology fully, limiting verbal orders, and improving patient verification throughout the medication-use process.

In the inpatient setting, nurses are the chief patient safety officer. Non-punitive measures are important part of medication error reporting as lends itself to reporting of events/system issues to prevent future mistakes and harm.

Totally agree with ISMP white paper Adverse Event and Error Reporting in Healthcare

Any reporting program that has at its core the punishment of healthcare practitioners and organizations is bound to fail in terms of gaining new knowledge about errors, as well as holding providers accountable for patient safety. While punishment may be warranted in rare instances for illegal or malicious behavior, mandatory reporting in today's health systems typically results in punitive measures against health care professionals and organizations involved in medical error, whether punishment is warranted or not. Therefore, mandatory reporting, with its attendant threat of punishment, has had the undeniable effect of suppressing error reporting and inhibiting open discussion about errors and their system-based causes. In truth, all reporting systems are fundamentally voluntary, and even mandated reporting may be avoided (Billings C. Presentation to Subcommittee on Creating an External Environment for Quality Healthcare. Jan 29, 1999) to escape the threat of punishment.

In essence, many of the mandatory systems are perceived as less than credible because they tend to assign blame rather than identify and correct the system-based causes of errors. Blame typically underpins accountability systems and may be a powerful disincentive to reckless behavior. However, blame also discourages reporting and is a powerful barrier to collaborative problem solving. The inclination to blame individuals is rooted in hindsight bias - a tendency to see a problem as much simpler once you are in possession of the full facts and outcomes. Hindsight bias renders it difficult for you to understand that the situation faced by an individual at the time of the event is very different than perceived after the event. The events typically reported to mandatory systems have resulted in serious harm, and outcome-based event analysis is especially prone to hindsight bias.

Equally important, reports received through mandatory systems often do not include information that is crucial and necessary for the identification of system-based causes of error and the selection of error reduction strategies that can offer the greatest chance for success. Any reporting program that is not built fundamentally on the reports of front-line practitioners is likely to be a waste of valuable resources. Currently, reports to existing mandatory systems typically originate from a designated person within a healthcare organization who is not necessarily one of the front-line practitioners most familiar with the error. Further, the information usually contains a description of "what" happened, not "why" it happened. Additionally, the person designated to report an adverse event to a mandatory system is often under considerable pressure to minimize the organization's exposure to liability and public distrust. Therefore, it is not uncommon for pertinent information, which is crucial for effective analysis, to be overlooked, unavailable, or simply excluded.

Such second-hand reporting is not nearly as valuable as front-line practitioner reporting to the experts who must analyze errors and suggest solutions. As a result, the IOM report notes that current mandatory reporting programs have been less successful in synthesizing and analyzing information contained in the reports and recommending broad system improvements to enhance patient safety. Moreover, personnel with current mandatory systems may not have sufficient expertise to understand the system-based causes of errors and the most effective means to error-proof systems. In such situations, the human tragedy of medical error is compounded because much of the important information contained in each error that could lead to successful system-based error reduction strategies may well have been overlooked.

[martymoose, BSN, RN]

I'll tell you- the customer service thing and med administration do not go hand in hand. I constantly worry and double check everything I do, because I am CONSTANTLY interrupted when I am giving meds. Call lights must be answered with so many seconds. pt that Im going in to give meds say they have to go to the bathroom NOW, not after their pills. of course that is a 15 minute fiasco, and no one else is around to help , as they are doing the same thing with the other pts.We used to have a sign to not disturb the nurse when they were getting meds. Well, that's gone. And it's not getting the meds, it's administering them. You can tell these patients til you are blue in the face that you cant do that ( whatever their request is) right now, as it's important you dont make any mistakes with your med pass. NOPE, they don't want to hear that.They don't care. It's the me me me thing. No wonder more mistakes aren't made

[Overland1, RN]

LPNs / LVNs also make medication errors.

As do some physicians, but the nurses usually set them straight. I still recall the one who ordered Atropine for what he thought was SVT (was really rapid A-fib). What he should have ordered (based upon his interpretation of the ECG) was Adenosine, which (even with 6, 12, & 12) would have done nothing anyway. We all refused to give it; he was told that if he gave it, we would have the crash cart ready. Oddly enought (and fortunately), the cardiologist walked in and took him aside to set him straight. We never saw him for a long time after that... maybe he got promoted or something.

[Overland1, RN]

For those of you in Nursing school who want to freak out and annoy your instructors, state the 'five rights' as "TRAMP... Time, Route, Amount, Medication, and Patient",.

Or not.

[mind_body_soul RN]

We were taught TRAMPED (same as above with the addition of Expiration date and Documentation)