Giving the wrong meds.

[Julie19, CNA]

I'm a CNA at an ALF. I went in Sunday night for my shift and the new day shift nurse was still handing out her evening meds. The night shift nurse had just arrived and began helping her get finished.

Next thing I know, day shift nurse walks out of a resident's room, stops, then screams out, "I just gave that resident another resident's pills!!"

To make a long story short, we kept an extremely close eye on this particular resident all night because she has normal BP but one of the pills given to her was for high BP. It rode very low all night; she felt terrible. Thankfully, we didn't have to send her out but it was still a highly stressful night.

The nurse received no disciplinary action and that really bothers me. She didn't even show remorse. She just went home and didn't even call to check on the resident. Have you guys ever experienced this? How was it handled?

[wooh, BSN, RN]

What do you think would be sufficient? A public flogging?

[sbostonRN]

I'm sure the new nurse felt very sorry for her error. In nursing, it's very difficult to separate work from personal life, so I can see why she wouldn't want to call and check on the patient. Plus, if the night shift was coming on, she would probably be sleeping.

Medication errors happen all the time unfortunately. If this was her first error, she probably received a verbal or written warning and will hopefully be more careful in the future.

[proud nurse, BSN, RN]

We had an agency nurse give insulin to the wrong patient (a non-diabetic with the same first name and last initial). The resident was put on the 24 hour change of condition report. We monitored her closely, and the agency nurse was written up for a med error. The incident seemed to bother the nurse, but she didn't call to check on the resident's condition. I imagine she was embarassed, since she failed to do her 5 rights.

[amoLucia]

You are NOT on the other side of the management door. A major error like this does require a thorough investigation and more may have occured between the Admin and that newbie nurse, and YOU are not needed to be included in that review. You are not the judge of what is or is not the appropriate level of concern by that nurse. Did she drive home in tears? Did she get any sleep that night? Did she speak with the boss on the phone? Do you know any of that?

What makes you feel like you have the right to be her judge and jury? And what is an appropriate disciplinary action - public flogging or stoning? Sackcloth and ashes? There has to be more to this sad incident for which you are not privy.

I'm reminded about something in the Bible, about 'casting the first stone'. And something about 'living in glass houses' comes to mind; 'walking a mile in my shoes', also. I can sympathize for that new nurse. I do hope she learns from her error and will be a better nurse for it.

This truly is a situation between her and mgt.....NOT YOU. Leave it to them.

[Pepper The Cat, BSN, RN]

How do you know that she rec'd no disciplinary action? That would be between her and management. No one else should know about it. As for calling in, what would that accomplish? Mistakes happen. This was a bad one but hopefully she will,learn from it and become a better nurse.

[Boog'sCRRN246, RN]

On my floor, med errors aren't handled punitively. We aren't written up or disciplined per se. Med errors are always handled as learning opportunities...unless someone tries to cover up the error. When something carries the potential for punishment, it's surprising what people will do in order to avoid being punished.

[BrandonLPN, LPN]

EVERYONE makes med errors once in a great while. Anyone who says otherwise is either lying or to stupid and unobservant to notice.

What business of yours is it how or if she's being punished? If you're planning on being a nurse you better learn fast how to tone down the immaturity and the "drama queen" factor.

[tnbutterfly - Mary, BSN]

moved to nursing and patient medications.

please refrain from name-calling and personal attacks. the op has posted a legitimate concern, to which members may respond without the judgmental tone.

[PeepnBiscuitsRN]

I think the fact that she "screamed" I just gave that patient someone else's medication is a pretty good indication that she acknowledges what she did. From that point on, what should she have done? Thrown herself on the floor and kicked and screamed, rend her scrubs and cry?

It's been said already, you wouldn't know if she received any slap on the wrist or a bawling out. You're night shift, she's day shift. You don't know if she drove home in tears, replaying the whole thing in her head repeatedly. Calling to check in on the patient? How about giving her some credit to know what meds she gave and what those meds do, and knowing that the right people know what happened and they'll call if the poo hit the fan.

If you were in her shoes, I would guess that you'd be pleased as punch to not have disciplinary action taken against you.

[tokebi]

On my floor med errors aren't handled punitively. We aren't written up or disciplined per se. Med errors are always handled as learning opportunities...unless someone tries to cover up the error. When something carries the potential for punishment, it's surprising what people will do in order to avoid being punished.[/quote']

Exactly.

It's pretty sad that it was 1999 when IOM report "To Err is Human" came out. Let me quote a paragraph here:

[h=3]Why Do Errors Happen?[/h] The common initial reaction when is to find and blame an error occurs someone. However, even apparently single events or errors are due most often to the convergence of multiple contributing factors. Blaming an individual does not change these factors and the same error is likely to recur. Preventing errors and improving safety for patients require a systems approach in order to modify the conditions that contribute to errors. People working in health care are among the most educated and dedicated workforce in any industry. The problem is not bad people; the problem is that the system needs to be made safer.

It has been over a decade, and yet punitive actions are still rampant especially in LTC.

Did this new nurse receive adequate orientation? Was she under pressure to rush (very likely since she was already late)? Was it a busy day and she was fatigued?

Errors should not happen but nurses are human. We face so many environmental, systemic barriers. Sadly, still too many people want to punish the nurse instead of helping the nurse to avoid error in the future by improving the system.

[imintrouble, BSN, RN]

I would guess that for every one nurse who admits their mistake, there are ten that don't.

Kudos to that nurse for considering the health of her pt, before her possible write up or discharge. Because I guarantee you she weighed the two before she announced her mistake.