A sobering story-------

xoemmylouox, ASN, RN · Dec 1, 2015

I'm not sure if this has been mentioned yet, but the child was VERY ill to begin with and only the cardiologist somewhat indicated this overdose led to the death of the child. They child might have ended up dying regardless. (This by no means excuses the mistake).

The nurse made a mistake. It was a grave one. We all make mistakes. Some of us are just lucky enough that they haven't killed anyone. She shouldn't have been distracted when handling a medication, she should have double checked, she should have followed her 6 rights.. This is where being too comfortable in your job or not in the moment is dangerous.

MD's make mistakes that lead to the death of patients and I RARELY hear about it. I doubt they would have to have another MD "supervise them" EVERY time they wrote a medication or performed a simply procedure, unlike this nurse who needed someone to watch her "every" time she dispensed medication.

The hospital and BON made an example of her. I wonder how many other mistakes have occurred at that hospital that went unreported because staff were fearful of the consequences?

Horseshoe, BSN, RN · Dec 1, 2015

This has nothing to do with the issue of how she was treated after this error, but I keep reading how this was her first error ever.

If a nurse told you "I've been a nurse for 25 years and I've never made a medication error," what would you say? I know what I would say. I'd say (at least to myself), "well, either you are lying or you didn't realize you did, but lady, you've made a medication error in 25 years of nursing. And the ones who don't realize they have are scarier the ones who own it."

I really don't believe for a moment that this was her first med error. It just happened to be a huge one, but come on. Somewhere along the way, in a span of 25 years, she made errors. We have ALL done it. Usually they are relatively benign, like we got the timing wrong, somehow missed the order, or maybe gave po when it was ordered IV, or something along those lines.

Yes, this incident could have been handled so much better. She didn't deserve to be treated practically like a criminal.

cindy_rn456 · Dec 1, 2015

That doesn't mean I'm unemployed.

cindy_rn456 · Dec 1, 2015

I'm certainly hoping it's BS. Otherwise Cindy holds some responsibility at seeing someone who committed three sentinel events in one night come back to work. Those actions are definitely enough to raise alarms to police.

EVERYONE missed the part where I said I DID REPORT it to the night supervisor and DON and the CHARGE nurse who did it still was allowed to RETURN to work and is still employed there. Period.

Horseshoe, BSN, RN · Dec 1, 2015

EVERYONE missed the part where I said I DID REPORT it to the night supervisor and DON and the CHARGE nurse who did it still was allowed to RETURN to work and is still employed there. Period.

No one missed that. But several have wondered why this guy was not reported to law enforcement by the person who witnessed the events.

cindy_rn456 · Dec 1, 2015

No one missed that. But several have wondered why this guy was not reported to law enforcement by the person who witnessed the events.

The police were called!!! My point was it was never REPORTED TO THE BON!!

cindy_rn456 · Dec 1, 2015

No one missed that. But several have wondered why this guy was not reported to law enforcement by the person who witnessed the events.

Im not going to sit here and thumb war

With you or anyone about the entire details of this event. I'm here sharing my personal experience and opinion about this article. I know I did more than the other nurses on the floor who pretended like they didn't see anything. I was the only nurse who told my superiors or did anything. You can keep your digital judgements to yourself! k thanks.

sailornurse · Dec 1, 2015

The police were called!!! My point was it was never REPORTED TO THE BON!!

But why didn't you report it to the BON? We are a profession that "self polices". You have a responsibility as a patient advocate to report this to BON.

cindy_rn456 · Dec 1, 2015

Im not going to sit here and thumb war

With you or anyone about the entire details of this event. I'm here sharing my personal experience and opinion about this article. I know I did more than the other nurses on the floor who pretended like they didn't see anything. I was the only nurse who told my superiors or did anything. You can keep your digital judgements to yourself! k thanks.

cindy_rn456 · Dec 1, 2015

I'm not sure if this has been mentioned yet, but the child was VERY ill to begin with and only the cardiologist somewhat indicated this overdose led to the death of the child. They child might have ended up dying regardless. (This by no means excuses the mistake).
The nurse made a mistake. It was a grave one. We all make mistakes. Some of us are just lucky enough that they haven't killed anyone. She shouldn't have been distracted when handling a medication, she should have double checked, she should have followed her 6 rights.. This is where being too comfortable in your job or not in the moment is dangerous.
MD's make mistakes that lead to the death of patients and I RARELY hear about it. I doubt they would have to have another MD "supervise them" EVERY time they wrote a medication or performed a simply procedure, unlike this nurse who needed someone to watch her "every" time she dispensed medication.
The hospital and BON made an example of her. I wonder how many other mistakes have occurred at that hospital that went unreported because staff were fearful of the consequences?

good point about the MDs. They mostly worry about lawsuits

Horseshoe, BSN, RN · Dec 1, 2015

Im not going to sit here and thumb war
With you or anyone about the entire details of this event. I'm here sharing my personal experience and opinion about this article. I know I did more than the other nurses on the floor who pretended like they didn't see anything. I was the only nurse who told my superiors or did anything. You can keep your digital judgements to yourself! k thanks.

You are not a moderator. You cannot command that posters here not respond to your comments, nor can you dictate content that is not against TOS. Everyone here has the right to state their opinions as long as they conform to the TOS. You do not have the right to censor the members of AN.

Horseshoe, BSN, RN · Dec 1, 2015

The police were called!!! My point was it was never REPORTED TO THE BON!!

Okay, now suddenly you decide to mention that the police were called after you insisted that you figured the DON and charge would "handle it" as promised and made zero mention of LE involvement? Sorry, not believable.

And yes, if you witnessed these events as you proclaimed, you should have reported it to the BON yourself.