Med error or not? Please advise

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    I have worked at the same SNF for a year and a half. Although i question the moral of the majority of the staff,.i stay for the patients
    A couple weeks ago, the RN asked me to write a telephone order for a hospice pt changing her Norco from TID to BID at her request. I saw the fax from the MD and kind of wondered why she had not contacted hospice, but seeing the fax, i did it as a favor seeing she was extremely busy and the pt was my responsibility that day. All she had asked me to do was the telephone order, so i did it and left it be. About two weeks later, i war confronted by another nurse asking about the order. She wanted to know why i wrote it, and why i didn't put it in the MAR. Because it wasn't in the MAR, we had been administering it TID. I was so busy that day, i couldn't remember doing it. I called hospice to clarify, and sure enough they told me the order was TID. I made a new telephone order for TID, and then was sent home for being sick. That night i remembered everything about the fax. The next day i went to work, found the fax and was ready to show my supervisor explaining the situation, only to find i was completely off the schedule. I called my DON only to have her tell me i was suspended, i was under investigation, but didn't give me a reason!
    I met with her in person 2 days later. Evidently there were several med errors caught, but I'm the only one suspended. I explained the situation and the supervisor managed to blame everything on me.
    I told her hospice never changed the order and they are responsible for the meds. She said the RN was not familiar with the pt and didn't know she should contact hospice and not change the order in the first place. She also said because i wrote the order, it was now in effect and because i didn't transcribe it into the MAR, i was technically overdosing the PT.
    I am now suspended until further notice. I also have to reorient passing meds (with the RN that made the mistake). After that, i have to have a pharmacist follow me to make sure I'm competent enough to pass meds.
    Sad thing it's had i known the RN wasn't going to transcribe the order being she had my MAR, i would have.
    Although the RN made a mistake not looking at the chart, changing an order when she shouldn't have, and didn't follow through with her quirk r, she has no consequences.
    Yes, i have learned A LOT from this situation. But, now i need a different job, and I'm pretty sure they're going to report me to cover their behinds.
    Also, what about the other med errors they caught by different people? Why are they not in trouble?
    I'm so upset and depressed and very bitter. Im thinking about contacting an attorney. Can someone please advise me on what i should do? I'm stuck!!
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  3. 8 Comments so far...

  4. 1
    I am finding your post a bit confusing, did you take the telephone order or not? was the rn a hospice nurse not an employee of the ltc?I would get the retraining so on your record you are deemed competent and then move on.If they report you to the BON it will look worse if you did not comply. Do not be too hard on yourself you made an honest error
    AngelicDarkness likes this.
  5. 4
    First off, you errored in writing an order that another nurse took over the phone. You basically said you heard the order and wrote as such. That being done, you are responsible for putting it on the mar. If the order was bid and was not changed by you, the one who wrote the order, then the pt has been overdosed.

    Take the retraining and chalk it up to a lesson learned. As the previous poster said, if it is turned into the board of nursing, it goes better for you if you complied with retraining. I hope you do have a better day.
    KelRN215, AngelicDarkness, psu_213, and 1 other like this.
  6. 1
    You should never transcribe an order you didn't receive personally. It's your license on the line.

    However, I disagree that not putting it on the MAR is part of your mistake. How do people know the medication was TID? Who ever noted it on the MAR and did the 24-hour check should be the one accountable for that.

    There are always checks and balances. If I wrote an order and didn't carry it out, the next shift should have checked the chart and carried it out before giving the medication. It's not just you who's responsible. It's failure of the system.
    LStollard likes this.
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    If you transcribed a telephone order, but failed to note it in the MAR, you kind of skipped the most important part of the process.... I'm reminded of that Seinfeld episode where the car rental company took his reservation, but failed to actually hold the car for him..
    Jerry: I don't understand. Do you have my reservation?
    Rental Car Agent: We have your reservation, we just ran out of cars.
    Jerry: But the reservation keeps the car here. That's why you have the reservation.
    Rental Car Agent: I think I know why we have reservations.
    Jerry: I don't think you do. You see, you know how to *take* the reservation, you just don't know how to *hold* the reservation. And that's really the most important part of the reservation: the holding. Anybody can just take them.
    KelRN215 likes this.
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    Thank you all for your replies. I do appreciate it. Just to clarify and another question as I am somewhat of a new nurse and this is the only nursing job i have had, it was not an order taken over the phone. It was actually a fax that was sent by the RN and approved by her MD. The fax was shown to me. The RN told me to TO the order. My mistake, I assumed that if I did so, she would do everything else. Yes, a 24 hr check was done, and i will be looking at how it was overlooked.
    Again, thank you all for your time and advice.
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    In all seriousness though, I agree you should just accept the suspension and reeducation and move on. It's not as serious as it seems now. You will survive this.This sort of thing has happened to most nurses. Learn from it, but don't beat yourself up over it.
    With that said, I'm a little puzzled as to why you're upset no one else is being punished. Yes, others made mistakes. Most places, 3rd shift double checks all the days orders to make sure they were carried out. Obviously they dropped the ball as well. But I question why you want them to be punished, too. Is it due to the principal? Or, more likely, is it just bitterness? Stop and be honest with yourself. Yes, 3rd shift (or whoever) made a mistake. But their mistake was not catching an error *you* made. Do you really want someone else to be punished for that? Really? And you say management isn't punishing other nurses for their mistakes? So what? How do you know, first of all. And, second, it isn't your business.
    If you have the mentality of "If I'm in trouble, everyone else should be too", you're going to have a long and miserable nursing career ahead of you.
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    I hope i didn't Come off sounding like i wanted other people punished. It's not that. I just want to be treated the same as others. I respect constructive criticism and expect my mistakes to be pointed out. What i don't think is fair is being punished for other peoples errors and having excuses made for their mistake. There is a lot more to this story as well as a lot of history that I'm not going to put out here and that has made me feel the way i do.
    I do want to walk away from this having learned something and i don't want it to be out of "bitterness". Maybe the way i wrote this blog was more out of emotion. Again, i dont mind my mistakes being pointed out, and if there are consequences for my mistakes, so be it. I just feel it could have been handled a lot differently and using me to cover someone elses mistake is hurtful and damaging. Further education will no doubt be beneficial, i just don't want this to follow me.
    I have no problem taking accountability for my mistakes. With my experience at this facility (and um not the only one who sees this), I'm the ONLY one who is honest about my mistakes. The while point of this blog was not to blame others our sound bitter. My question was...who's responsibility was it to transcribe the order? The RN requested the change, and her being busy, asked me to TO the order. So by me aggreing to TO it, and her saying she would take care of the rest, was it my responsibility to follow through with everything else?
    I think I've already had my questions answered. I am going to comply with what they're requesting and will walk away having learned a very valuable lesson.
    On another note, I'm not sure how to explain this situation in future interviews. I don't want this prohibiting me from moving forward.
  11. 0
    Just be open with future interviewers. Most of them would rather here it from you, than to find out later. I'm sorry to hear OP, but on the upside it is a learning lesson. I hope you are feeling better


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