What Would YOU do?

[Paprikat]

A question: What would you do?

A nurse in my facility on the morning shift gave out three racks of supper pills at breakfast. She did not say a word to the oncoming evening shift. The evening nurse gives out the three racks, then on the fourth one, she realizes that the pills are out of sequence (the meds are blister packed). She calls the nurse at home who gives her a vague answer about "prepouring" the meds, but not actually giving them. The nurse files a med error report and four days later, it is charted (late entry) on some residents that a med error occured, but the resident was "monitored." Now how can the evening nurse "monitor" something SHE DIDN"T EVEN KNOW OCCURRED?!? She then double doses some of these people (including heart meds and Coumadin). I am so disgusted. Normally, I am supportive of my fellow nurse colleagues, but I think this one should be canned. Not for the error, but for the attempt to cover it up. Had it not been for this nurse's sharpness, she may have gotten away with it. The management has done nothing to her and I am so irritated. Should I let it go? Can a person call the governing body? Your input is appreciated.

TKS!

[dianthe1013]

Eeep. I'm inclined to agree, actually.

Everyone makes mistakes; that's human nature. But... Did the morning shift nurse actually catch that she'd goofed? It seems so, but I'm not totally sure. If she realized she'd made an error and just "swept it under the carpet," then I do NOT envy you for working with her. That goes beyond dangerous into negligent.

Your supervisor isn't fazed by this? Pfft. That's insane.

Donna :)

[Paprikat]

Yes, because she was the one who charted the late entries, only punched 3 of the 6 racks. Apparently one of the residents told her, "I get these at supper." She is a new grad, but I believe that she must be accountable for her actions. The evening nurse is an excellent nurse and would have been more than understanding, but she chose not to say anything to her.

[fedupnurse]

The newbie sounds dangerous. Is she still on orientation with a preceptor? Sounds like she knew what she did since a patient told her so, and she could definetly be sued for malpractice and I would think lose her license. In New Jersey the State Board of Nsg. clearly states the 5 "rights" of medication administration and I believe if she were practicing here she would lose her license. Trust me, the suits here would probably do the same if she was new or liked by them, but Risk Mgmt. sure wouldn't over look the problem. I'd document the incident to them because she is putting the patients lives at risk and those that follow her at risk as well.

Hope she gets the remedial education she needs. Best of luck to you, your colleagues and mostly, the patients!

[Tiiki]

That med error could have had catastophic results. Is there no follow-up to an incident report? When we fill out a med-error, the doctor must be notified immediately, as well as the supervisor. The doc must come up & examine the pt. Both those nurses heads should be on the chopping block. The first for giving evening meds, the 2nd for double dosing. Were there any reprocussions with this? Did any of the patients get ill? I am surprised the manager has such a laissé faire attitude, because had something gone wrong she'd have a lot of people to answer to.

Let me know the outcome!

Ciao

:)

JO

[Stargazer]

Paprikat, I agree with you. Med errors are nearly always forgiveable. Attempts to cover them up, and false documentation are not.

What if one of those pts had developed a bradyarrythmia from dig toxicity or had a GI bleed or a hemorrhagic CVA from a Coumadin OD? Would either of these nurses have 'fessed up then?

If it's just your immediate manager who's doing nothing, then I'd be inclined to go over his/her head or to Risk Management. If it's clear that your institution isn't prepared to do anything, it's tempting to go to the state BON--but if you don't have documentation and/or eyewitness accounts to back up your story, the BON may be pretty powerless to do anything.

Other solutions you might try:

1. Peer pressure. Confront them, possibly with a few of your colleagues, make it clear that you know what happened and that this is unacceptable, both from a pt care and from a legal standpoint, and any further instances will be reported directly to the BON.

2. Have someone from Risk Management, or Legal, or the Ethics Committee come and give a talk on pt care issues, including med errors and the negative consequences of failing to report them.

Unfortunately, you need to keep an eye on the newbie. She sounds unsafe and I wouldn't be inclined to believe anything she tells you or charts at this point unless you or someone you trust sees it with your own eyes.

[shay]

What about reporting her to an ombudsman? Do y'all have those in Canada?

She sounds dangerous, and I agree w/everyone else. Report her, somehow, to someone who will TAKE ACTION. Maybe the b.o.n.?

[Paprikat]

The second (evening) nurse knew NOTHING because the day nurse never told her, so she came on and gave the pills and then only when she got to the fourth rack did she realize something was wrong, so it is not her fault. She did the proper procedure of reporting it to the manager. She would NOT have given the meds had she KNOWN that the day nurse already gave them and would have been able to monitor the patients properly. She is also angry that nothing has been done......

[sasseynurse]

Here's my 2 cents. I'm not sure what a "rack" is because we use bubble packs in my facility. Our medicines are organized in drawers according to AM, PM, and Odd Times.

How did morning nurse confuse the pills? The MAR should list all meds and the times to be given. Was she reading the MAR or just pouring pills? Coumadin in particular is given during the evening at my facility and Digoxin is usually given in the morning after breakfast.

If I were in the situation, maybe I might consider speaking with the "day nurse" and ask her/him how this happened. As an evening nurse, I would be looking at the packaging to see if pills were missing. One would hope that this incident is "one time thing" and the "morning nurse" has discovered the difference between AM meds and PM meds.

Using a red pen or marker in the MAR helps me when I pass PM pills. Marking the cards with AM in black and PM in red is also a help, if your facility doesn't have rules against marking cards.

As for what you can do, be strong in your position and never hesitate to question unethical practices. You may be unpopular with the nurse who made the mistake, but isn't patient safety worth more? Sometimes, supervisors are taking action quietly while they appear to be nonchalant to the rest of the staff.

Just my humble opinion.

[Paprikat]

The meds are on cards and then placed on racks. There is a space for bkfst, lunch, supper and HS, and the racks are clearly labelled as such. The coumadin is given in the evening, and I am not sure exactly why she gave out the supper pills when she worked the morning shift. The eve nurse is casual, so she didn't know what sequence the blisters were in, like I said, she did realize when she hit the fourth rack and then the blisters were out of sequence. Thanks to everyone for the replies. I am gald to see that I am not over reacting.....