Giving the wrong meds. - page 2

by Julie19 7,994 Views | 15 Comments

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... Read More


  1. 1
    Quote from Boog'sRN246
    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.
    Exactly.

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

    Why Do Errors Happen?

    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.
    Hygiene Queen likes this.
  2. 6
    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.
    Last edit by imintrouble on Jul 19, '12 : Reason: spelling
    amoLucia, Hygiene Queen, AnitaHug, and 3 others like this.
  3. 4
    As other's have said disciplinary action may not even have been necessary. Disciplinary action could, in the future, cause people to be less likely to admit their errors.

    Humans make mistakes, she owned up to her's right away, and the proper monitoring of the pt was implemented. After the error, it seems like everything was done correctly. Hopefully she will be more careful in the future. Everyone needs to move on. (Plus, as others mentioned, there may have indeed been disciplinary action, but that would be between the nurse and management...if I was that nurse I certainly want it to be kept private).

    Now for the issue of remorse....what is the proper amount of remorse for this situation? One call? Call every hour? Come back in to work hours later just to make sure? If she does any of these things, does that mean she is remorseful or just that she wanted to cover her butt? Having remorse does not have to be a public act. Also, I think it is best for the nurse and for her future to be able to leave work at work (even so, how do you know she did not spend the whole night awake tossing and turning in bed, unable to sleep because of the error?). What's done is done and no matter what she does after she leaves work...no matter how many times she calls...it is not going to change the outcome for the pt.
  4. 8
    Quote from Julie19
    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?
    Why disciplinary action?
    How about looking at the situation and figuring out how it happened and how to prevent it from happening again?

    As for showing remorse, well, I'm sure her head was just full thinking about it.
    She was probably upset and just wanted to think about something else when she got home.
    I agree with whoever said that she might even be totally embarrassed.

    If she didn't really care, she would have kept her mouth shut and let everyone wonder why the resident felt terrible.

    I once double-dosed my pt with Ativan.
    I notified the doc, the POA and the pt and monitored the hell out of him.
    I did not burst into tears or throw myself to the floor in a panic.
    I was very calm because I had to be.
    I was able to analyze what happened and I guarantee you, I won't make that mistake again.
    But what would I have learned if I had been tossed to the wolves?
    Also, would you have interpreted my calmness for lack of remorse?
    I surely did feel like an ass and wanted to have a fit, but there was nothing to be gained from behaving that way.

    Trust me, you don't want them to be so quick with discipline when it comes to med errors... because when it is your turn, you won't be so happy about that.
    MedChica, Kitty-RN, KelRN215, and 5 others like this.
  5. 6
    Some of my favorite moments in life have been when an aide decides she knows better than anyone else--including other nurses or the nurse manager--how any given situation should have been handled (and it was, of course, handled incorrectly, according to the aide).

    Thank heavens my fate has never been determined in this manner.
    BluegrassRN, imintrouble, ktwlpn, and 3 others like this.
  6. 3
    Quote from RNsRWe
    Some of my favorite moments in life have been when an aide decides she knows better than anyone else--including other nurses or the nurse manager--how any given situation should have been handled (and it was, of course, handled incorrectly, according to the aide).

    Thank heavens my fate has never been determined in this manner.
    Oh my lord!
    I just went back and reread the OP.
    My eyes must have swept past the part where she mentions that she is a CNA.
    I just wasted 5 minutes of my life in my above post.

    Alrighty then.
    RNsRWe, imintrouble, and psu_213 like this.


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