I made a med error - page 4

by southern_rn_brat 18,730 Views | 56 Comments

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... Read More


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    Quote from southern_rn_brat
    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?
    Yes.. you were honest and contacted everyone.
    I made a med error and after that I made out the report, notified the next shift coming on ,monitored the patient and did all the necessary things a prudent and honest nurse does.
    2 days later I am told they cannot trust me.
    My gf worked at the same place and afterward I asked if he had any effects of the drug and she told me "NO" .\
    I thought that being honest was just too much for the nursing home. and If I had not reported it...I would still have the job.
    SNF units are crazy.
    I hope you carry your own liability insurance. Cause the hospital may not back you unless you are well liked.
    what state are you in?
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    oh my god i feel so sorry for you! you handled it very well and responsibly. i hope i never have to go through that. on a more personal note, if it were me heck yeah i'd sue! this is a serious matter, and should not be taken lightly cuz you said it was an accident and apologized for it. however, i agree with a previous post which questioned how he got the med without a valid prescription. second, (not trying to shift the blame) but i thought pharmacists were paid so much to spot such errors and call when they suspect something is wrong before filling it. from what i've been told in school so far, it is the responsibility of the nurse, the charge nurse, the physician, and the pharmacist to make sure mediction errors don't occur. they are all supposed to "double-check" eachother's work. this is why it is so easy to sue a facility because they figure somebody should have caught it.
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    Wow. I agree, it sounds like the patient had no harm done to them from. The dizziness can be from a number of including the dialsyis making him hypotensive. So they can't prove a specific unless the patient had a fall and hurt himself as a result of it. Thank God you did the right thing though.
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    I havent heard anything yet. They keep telling me not to worry.

    lol
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    Quote from xrockstheheart
    medication error rate is about 25%. The hospital should inform the patients that this is so when they come into the hospital, it is a risk they take. You need to read, "Nursing as a Function of Time" , www.Nursewise.com and you need to go to the Medication Error people, i forget what their name is. And get your facts straight. You know I take that med and nothing happens to me. the standard of proof here is did the patient suffer any consequences, the ans is probably no. Now you know not to call the family. the biggest thing here is that you are a supervisor and you shouldn't be doing this, that's probably where they will catch you. My pharmacy send me the med, twice, once labeled with bid and the other labeled 1/2 bid. well i didn't look and took the 25mg and i was woozy for a couple of days. So I guess i made a med error on myself, the rx sure made one. Just to let you know I always mark my med sheets, with a code if there is short staffing, etc because this increases the probability of error and adverse events, like people dying.
    I've been reading the post and this is what i would do
    1. I would cancel my malpractice insurance.
    2. i would not worry about a suit if the patient did not suffer harm
    3. the medication error rate is high about 25%, you might want to check with the Institute for Safe Medication Practice.
    4. You might want to report your errors to them so they can have better data, your name is protected.
    5. the state board is not going to get you for a med error, they might reprimand you if someone dies
    6. the best way to decrease med errors is to decrease the number of meds. meds that are not necessary in the acute care setting should not be administered. You shouldn't be wasting a nurses time with calcium for osteoperosis, when it isn't going to tx overnight. this is a tx doctors use so they can bill. you shouldn't be giving dopamine on the med floor when it doesn't work, they just do it to keep the pt in the hospital because they can bill more.
    7. a pharmacist fills thousands of rx a day, that's why they get it wrong, and they get it wrong a lot
    8. if you are a nurse you are going to have a med error, if you haven't had one you are not a nurse, or you are a liar
    9. most med errors occur at night, and they don't get caught by the nurse that made it, it's caught by the next shift.
    This just goes on and on. people. They do not cover this in school, sorry you freshman, you need to read,
    mommasgirls likes this.
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    Quote from southern_rn_brat
    I havent heard anything yet. They keep telling me not to worry.

    lol
    This is my personal opinion. I would respond as if the family would sue. But most importantly, I would start now gathering evidence to use toward defending yourself. (hopefully, you won't need it but you will be glad you have if you did) Make copies of your facilities policies and procedure regarding discharge process and administering medications. I would suggest that you write an objective account of what occurred that day while your memory of the incident is good. Be mindful that your written notes aren't necessarily protected from discovery in lawsuit. But if there is question, your written documentation is all you have to defend yourself. Review the patient's chart and look for anything that you omitted and that might be questioned. The reason I tell you this is that you cannot assume that you would be sued immediately, it may be a year or more before you see or hear anything about this and it becomes harder to remember any info. You can't assume that your employer won't report you to the BON, you can have the greatest relationship in the world with your immediate supervisor, but an institution will always protect themselves first and all it takes is for someone "upstairs" to become involved. People have spoke of not getting malpractice insurance -- this is my take. You are more likely to be reported to the BON than to be sued for malpractice. There are policies that will pay for a lawyer if you have to appear before the Board. However, I also understand the other side. I was named in a lawsuit once (the case was eventually dropped) but I was named because I was the patient's nurse that day. At that point, whether or not I had personal coverage was inconsequential, I had already been named. Would they have pursued me indiviually if I had personal coverage, that I don't know. But they always have to prove that your direct actions caused harm. So, coverage is an indiviual decision, most lawyers I had talked to recommend you carry it.
    Last edit by mydesygn on Apr 21, '05
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    I work in Risk Management. Everyday we hear someone threatening to sue but if a lawyer takes this case, he's probably doing it pro bono! He's not going to make any thing off of it and neither is the family! Mainly because he has no case. I agree with Lawnurse: bad medicine has to lead to bad outcome and from what you've told us the error caused no harm.

    Remember that no one gets up saying "I'm going to go in and kill someone today". We are all human and go into work with the best intentions. Errors happen. That's why we look at systems and processes these days rather than at the person! I'd be interested in looking at what was going on that could have contributed to you making the error. Were you distracted? There's all sort

    I know that feeling though and I'm sure you felt your stomach sink to your feet when you heard about it. You break out into a cold sweat and wish you could crawl under the floor! I've been there. If you weren't concerned I'd be worried. Hang in there! You have done the right thing! We have to disclose errors to patients and families. I realize that sometimes it really isn't something that is neccessary...like giving someone and extra pain pill, etc... especially if it doesn't cause harm.

    Keep us posted on what's happening!

    Janie
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    I just agreed to the sympathy of all regarding your experienced . Nurses are not perfect , because of long hours of work , we are all prone to commit mistakes . And you should not really admit that you committed mistakes , that admittance gave them an idea to sue you. If you are certain that you really wrote the right meds , someone else gave them wrong medication. In the facility where i am working with d/c prescriptions should be written by the attending physician itself because they are the only one can transcribed the correct medications for the patients , and in some intances the doctors hand writing were sometimes difficult to read . If we encounter that kind of handwriting , we would call second party to read for us or else verify to the prescribing physician so we are not a sole responsible for the mistakes. We need to be extra careful in all the steps we need to do , espacially if your license as an RN will be at stake . Just imagine , you studied for so many years , spent a lot of money to finished that course , get years of experienced then suddenly with just a simple mistakes , youre life will be at mess . HOW UNFAIR IT IS FOR US ...
    Quote from 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?
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    Quote from closatssl1
    Lawnurse, I was wondering whether the nurse (southern_rn_brat) that prescribed the wrong medication can lose her license for this? I am currently in my last semester of nursing school, passing meds has been one of my biggest worries that I have for when I graduate. You work so hard to get through nursing school, and it is so easy to lose your license. What is your take on this? Thanks. :uhoh21:
    NO, SHE CAN'T. that is an issue at my facility. ONLY the state board of nursing can reprimand a nurse by removing her license from her. it has to be VERY serious offense to lose her license the first time she is called before the board. what she has done can NOT cause her to lose her license. if called before the board she can be placed on probation, attend classes, etc. and if they deem is serious enough she may not be allowed to practice nursing for a specified time period. the facility can report her to the state board of nursing for investigation of this med error and the proof will be on the nurse.

    it sounds like she works for a wonderful company as it looked at why the error happened and took steps to prevent it from happening again. doesn't sound like the facility placed the blame on her, therefore it doesn't sound like she will be called before the state board of nursing.

    i do not know if the family can call the state board and complain about this and thereby have the nurse called before the board. it is usually the office of long term care investigates allegations made by families or residents/patients. it is worth looking into.

    i do know the TN state board of nursing and the AR state board of nursing takes a dim view of anyone who purports they have the authority to suspend, place on probation, or revoke a nursing license. these boards will investigate and reprimand those who do so.
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    who ever gave the med, makes the error, there is a difference between an error and a mistake, according to the board. What we haven't looked is , IS There another solution, why don't meds have a code... BP/QD or GERD/BID, CP/NTG/PRN. Psy/Dep/QD, names are great but would this help? I don't know.If a doctors writing can't be read, it is his fault and his liablility, write him up, report him to the Board of Medical Examiners, sent them a fax, he doesn't need to know. everybody has a boss.


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