I made a med error

  1. I work in a SNF facility. I am one of the nursing supervisors. About one month ago I discharged a patient to home. On the discharge meds I transcribed Tegretol as Toprol. I also listed Toprol, so he did get that med but also got Tegretol.

    One week later I recvd a call from his dialysis clinic asking why he had been started on that med in our facility. When I pulled his chart from medical records I discovered that I had made the error on discharge. I immediately notified our doctor, who was in our facility on rounds, and showed her the chart. I notified my DON. I called the dialysis clinic and notified them so they could dc the med and then I called the patients sister at home and told her I had made an error.

    Today my administrator recvd papers from a lawyer. they are suing us over my med error.

    I remember when I talked to his sister to tell her of the error that she said he had been dizzy that week but otherwise no adverse effects of the med. But of course I am birthing a cow here.

    Has this ever happened to anyone else?

    I felt horrible when I found out I had made the error. There was nothing else I could do. What irks me is this sue happy mentality of the general public. Every day I see commercials on TV that say "let us sue the nursing home for you". I'm not blaming anyone but myself, *I* made the error. But why do people have to sue?
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  2. 56 Comments

  3. by   Jolie
    I'm sorry for your situation. You acted in the most professional manner when the error was discovered, and for that you should be commended.

    I have never worked as an RN in LTC, so this is probably a stupid question. When the patient was DC'd, wasn't he handed written scripts for his meds, in addition to your DC instruction list? My question is how did he receive this med without having a written script for it?

    Remember, anyone can sue (and it seems like most do), but actually proving damages sounds like a long shot in this case. Please document (in a private journal) your recollections of this entire event, from DC, to speaking with the patient's sister, to being notified of the pending lawsuit. Contact a local healthcare attorney for a consultation, and take your journal along with you.

    I suspect that this will all go away if it becomes clear that the patient suffered no harm.
  4. by   tommycher
    Bless your heart, keep your chin up! I have a feeling this will go nowhere, but I know that does not ease the anxiety much. Thank you for sharing, reminds us all to be extra diligent, once again.
  5. by   MickyB-RN
    When I pulled his chart from medical records I discovered that I had made the error on discharge. I immediately notified our doctor, who was in our facility on rounds, and showed her the chart. I notified my DON. I called the dialysis clinic and notified them so they could dc the med and then I called the patients sister at home and told her I had made an error.

    Today my administrator recvd papers from a lawyer. they are suing us over my med error. >>

    You acted responsibly and it is so ridiculous how sue happy people are nowadays. We are human and mistakes will happen. Do they want nobody taking care of others? Are nurses to be perfect? A bit too much stress if you ask me. Conscientious, honest and alert, yes, Perfect, no.


    Kelly
  6. by   Todd SPN
    How unfortunate. In my facility, when we get an admission two nurses must sign off on admitting med orders. After your seeing your post I'm going to suggest the same policy for discharge residents. As someone else asked, I wonder how they got the drug without a script.
  7. by   CoffeeRTC
    Quote from Todd SPN
    How unfortunate. In my facility, when we get an admission two nurses must sign off on admitting med orders. After your seeing your post I'm going to suggest the same policy for discharge residents. As someone else asked, I wonder how they got the drug without a script.

    When we discharge a resident, we will fill out all the meds on the discharge sheet, but a doc needs to write or call the scripts in. Even if it is transcribed wrong on the dc instructions...a doc still needs to order it....sooo who ordered it? Sounds like someone else is involved?
  8. by   Lawnurse
    to sue there has to be 2 things - bad medicine and bad outcome. I'm using these terms loosly - but my point is, there has to be a bad result. Feeling dizzy for about a week with no other effect...? Don't rely me here, but I'm guessing that's worth about $100 (that's one hundred dollars) in a settlement. In other words (to an insurance company), nothing.

    You did the right thing once you realized what you had done - that WILL matter in how this situation plays out. You mitigated very well - acknowledged your mistake and made all reasonable amends. If it goes any further, you need your own lawyer - not because of what you did so much as because the hospital's lawyers protect the hospital's interests, not yours - and they are vastly different!

    Good luck - but I've got a feeling this isn't going much farther. I work in defense, and it would be a laugh to go up against a plaintiff who's complaint was they were dizzy for one week... :chuckle
  9. by   Crumbwannabe
    Quote from kellymarie37
    ...edit...it is so ridiculous how sue happy people are nowadays.kelly
    yeah, and the pity is that the family isn't doing this on behalf of the allegedly 'injured' party who apparently suffered no injury. they just want some more in the coffers to pick over after the patient is deceased. then they'll end up fighting each other over it.
  10. by   Lawnurse
    I've been thinking about your situation for the past day, and some more things came to mind.

    Ideally, what should happen (although I understand you probably followed your procedure exactly) is that a call should be made to the family member to change or d/c the med - but no fault should be admitted. The family member should not be told there was an error.

    If this man's "adverse effects" weren't serious enough to report to a provider (and we know he is seeing his dialysis workers 3x a week) there probably is no legal injury.

    There is a huge debate going on right now about whether health care professionals should be allowed to say "I'm sorry" when an error occurs. Rediculous, isn't it? (Shouldn't we be suing the people you *aren't* sorry?) Apologizing appears to admit fault.

    BTW, if this guy does get, say, $100, his lawyer will get between $30 and $50. Plaintiff's lawyers only make money when they win - they take a percentage of the win, regardless of how much work they actually had to put into the case. So when plaintiff's lawyers are arguing a settlement, they're not truly arguing to get their client money - they are fighting for their commission as well. This is obviously a conflict of interest. This is also why p.'s lawyer put out commercials *seeking* people who *may* have been harmed.

    In contrast, defense lawyers get paid by the hour - i.e. proportionate to how much work they actually have to do on a case. And they don't go searching for alleged malpractice. I got flamed on a different message board on allnurses for saying I, as a nurse, could only stand to work defense - but you all can probably see why I feel that way.
  11. by   Tweety
    It amazes me that people sue too. It also amazes me that people are less than honest when they sue, this dizziness will turn into something more and big after the stories told. People also know that people settle out of court and they are going to get some money for a case they know they would loose, and maybe their hoping for that.

    Good luck and I'm sorry this happened.

    I'm a little confused how your SNF works. When I d/c a patient home, I write the meds down, but they still have to have a script. How does it work that you wrote the wrong med and the patient took it?
  12. by   southern_rn_brat
    Hi guys and thanks!

    Our dischage procedure was that the doc would see the pt, do her discharge summary, write orders to dc any meds she didnt want them sent home on and then she would sign a discharge med sheet that either I or the other nursing supervisor would fill the meds in for her. If the pt needed a narc she took care of that prescription herself.

    The discharge med sheet was then faxed to the pharmacy of the pts choice to be filled. This was easier than calling in huge lists of meds to the pharmacy.

    Looking back on it today...we are all kicking ourselves. It worked well for us and none of us considered what would happen in the event of an error.

    We changed our discharge procedure today. From now on we will have the medication list filled out for her PRIOR to discharge and she won't sign it until then.

    I feel just horrible that she is now involved because of my error .
  13. by   RNKITTY04
    Yes unfortunatly Tweetys right. By the time the family has their say so, the Toprol will have caused an "abnormally low HR and caused the Pt to be dangerously lethargic for a week, which in turn caused the pt a decrease in their quaility of life". What a bunch of crap!
    Good luck to you.
  14. by   Schmoo1022
    I am sorry this is happening to you. We rarely discharge anyone home, but on admissions now, I am going to recommend that we have a double check in place. I do not want to go through what you are now, nor anyone else I work with.
    Being a nurse is getting scarier and scarier all the time.

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