Patient labeling issue

[sleeplessinnyc]

Hi All, recently i have been called to my managers office because I put another patient's name on a potassium IV that was suppose to be given to my patient. The reason for this oversight is that the other patient was also on potassium IV. My manager gave me a final warning for this error. A union delegate was present and we filed for grievance. What is the appropriate level of discipline for labeling errors? I did all the five rights. Right drug, right time, right route, right patient and right time.

Thanks for your inputs.

[Rose_Queen, BSN, MSN, RN]

I can see a few issues with this: if the label does not have the name of the patient receiving the medication on it, then you have not completed all the rights (right patient- conflicting patient name can be seen as a medication error per hospital policy, even if it's the right medication). Also, by putting another patient's label on a med given to a different patient, you have violated patient privacy- the patient receiving that med can now read the name of another patient, and know that they are receiving a certain medication. Think about what this could mean if the drug were something like acyclovir- typically prescribed for HIV+ patients.

[Pepper The Cat, BSN, RN]

But you did not do th 5 rights. You did not give the labelled IV medication to the pt with that name.If I were the pt and saw IV meds with someone else's name, I would be worried about every other med you gaveme

[MunoRN, RN]

If this patient was also supposed to get the same dose IV potassium then the 5 rights were correct, regardless who the bag was "intended" for. Personally I think it's bad practice to put the patient's name on the bag unless it's labelled by pharmacy for this very reason; check the med to the patient and the order, don't just rely on a name on the bag.

[eatmysoxRN, ASN, RN]

Was the bag already labeled for another patient? If so I wouldn't have changed it especially on potassium IV.

[PediLove2147, BSN, RN]

I agree with MunoRN. Everything was correct except for the name on the bag? Doesn't seem like an med error, an error yes but nothing worth getting written up over.

[psu_213, BSN, RN]

Name on the bag of medication did not match the pt's name. This bag of medication was not meant for this patient. Seems pretty straight forward as a "wrong patient" med error. A bad one? No. Worthy of being fired? No. Med error? Definitely.

[Ruby Vee, BSN]

If you're at the stage of a final warning and had a union delegate present for your meeting, it seems as if you're already pretty far along the disciplinary process. If that is the case, then it's not a matter of whether or not this particular error is worthy of being fired over, it's a matter of a pattern of errors. Since you don't seem to be taking any responsibility for this error, I have to wonder if that is also a pattern. In that case, the appropriate level of discipline would be termination.

[sleeplessinnyc]

I am not saying i am not taking responsibility for this error. I am posting in the forum to ask for opinion and so far the census seems to be that I did made an error which I appreciate and accept. I forgot to mention that this is my first ever write up and that is why the final warning seems a little harsh. How did you get the impression that there is a pattern from what I posted? Just because it is a final warning does not mean that i have a pattern, the degree of discipline is up to management and in this case you have no idea if they are being fair so you should not infer.

[Ruby Vee, BSN]

I am not saying i am not taking responsibility for this error. I am posting in the forum to ask for opinion and so far the census seems to be that I did made an error which I appreciate and accept. I forgot to mention that this is my first ever write up and that is why the final warning seems a little harsh. How did you get the impression that there is a pattern from what I posted? Just because it is a final warning does not mean that i have a pattern, the degree of discipline is up to management and in this case you have no idea if they are being fair so you should not infer.

"Final warning" implies that there have been other warnings. Other warning implies that there has been a pattern. If this is your first ever write up, then it shouldn't be a final warning. If it IS a final warning, with union representation and all, then you're fairly far along the disciplinary process.

Nothing in your original post implies that you understand the seriousness of your error or are taking responsibility for it. I'm sorry you don't like my opinion, but you did ask for it.

[sleeplessinnyc]

Ruby, didn't I say that this was my first ever write up? there had been no previous warnings, that is why final warning for first write up seems harsh. I come to this comunity to seek opinion and support but you seem to want to jump to the worse conclusion and make assumptions of people that you've never met. I appreciate your opinion on the matter but not on what kind of nurse I am without ever knowing me.

[Rose_Queen, BSN, MSN, RN]

Ruby, didn't I say that this was my first ever write up? there had been no previous warnings, that is why final warning for first write up seems harsh.

Sleepless, depending on facility policy, different (more severe) infractions qualify for more stringent disciplinary actions. The OR I work in does this with leaving sharps in instrument carriers when sending them to the sterile processing department for cleaning and sterilizing. The first time it happens results in a final warning. The second time it happens is termination. It doesn't matter how long it's been since the first time; that infraction stays on your record permanently. This sounds like it may be a similar in your situation, and you should consult your employee handbook or ask your manager for clarification.