A sobering story-------

cindy_rn456 · Dec 1, 2015

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.

*** are you talking about? You and anyone can say whatever you want. I'm choosing not to reply to your opinion as its my right not to. K thanks horseshoe !!

cindy_rn456 · Dec 1, 2015

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.

Have a seat horseshoe! I don't care if you don't believe me!!! LOL I'm not here for your approval. I don't owe you anything and especially not a long winded detailed story about this particular instance. If the DON and administrators and LE didn't report it than I'm not about to give it that much energy either.

cindy_rn456 · Dec 1, 2015

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.

Read my comment very carefully!!! When I told the DON she said she would 'handle it' and that's all I ever heard back from her but like I said you can have a seat horseshoe.

Horseshoe, BSN, RN · Dec 1, 2015

*** are you talking about? You and anyone can say whatever you want. I'm choosing not to reply to your opinion as its my right not to. K thanks horseshoe !!

Really? I was referring to this:

You can keep your digital judgements to yourself! k thanks.

We really do not have to keep our "digital judgements (sic)" to ourselves as long as we adhere to the TOS.

Horseshoe, BSN, RN · Dec 2, 2015

Have a seat horseshoe! I don't care if you don't believe me!!! LOL I'm not here for your approval. I don't owe you anything and especially not a long winded detailed story about this particular instance. If the DON and administrators and LE didn't report it than I'm not about to give it that much energy either.

You chose to relate a story about a nurse killing three patients in one night. You said you reported it only to your superiors and that the offender was at work the next day. When posters expressed consternation about your response to an alleged murderer (or at least very dangerous person), your story changed a couple of different times. If you couldn't handle the possibility of feedback to your post, I'm not sure why would post such an allegation.

Every time you receive questioning about this alleged incident, your responses become more shrill. I for one hope it was greatly embellished, because otherwise there is a dangerous individual working with vulnerable people who will probably go on to kill more of them.

SmilingBluEyes · Dec 2, 2015

ERM ok can we get back to the topic maybe????

Horseshoe, BSN, RN · Dec 2, 2015

ERM ok can we get back to the topic maybe????

I forgot what it was...

Oh yeah! Poor woman who felt she had no other choice but to take her life. Sad story indeed.

applesxoranges, BSN, RN · Dec 2, 2015

I read the article. It is a sobering story, but I'm not sure what conclusions I am supposed to draw from it (it's also kind of weird to read the v. serious, rather melodramatic article, and then the little blurb at the bottom from the author about she has "restless feet" and is always on the hunt for the best cheesecake ...) The article makes the usual argument about how healthcare should be more forgiving of nurses' errors and not stigmatize nurses for making them, but the nurse featured in the article accidentally gave 10 times the ordered dose of a serious medication to a critically ill small child who died a few days later. I'm sorry that the nurse involved eventually chose to commit suicide, but, at the same time, how much forgiveness can the system afford? How much of a margin of error is acceptable? People who are sick and vulnerable are counting on all of us to get things right. I wonder how the author of the article would feel if it were her child who had received the overdose.

Ten times can be a simple misplace of a decimal point. Another location used a "prime" bag of insulin to prime the tub. Well, they always printed a rate on it of 99 ml/hr. This was never to be connected to the patient. Well, one experienced nurse who should have known better connected the prime bag to the tubing and flushed it. She then had the pump set at 99 ml/hr. This was insulin. Because of the double checks, we caught it.

Another example that was touching was the man who was a pastor and his child had a severe brain injury. He was misled about how severe the injury was (one doctor suggested his son may make some sort of family event that was coming up) instead of anyone telling him that his kid probably never would be the same. The kid ended up dying when a pharmacist miscalculated a seizure drug and then the RN gave it. The pharmacist retired and never heard that he forgave her for making the error.

I make people double check my math when I do calculations. I make them look at the insulin. Especially with kids drugs when you're dosing 1 mg/kg or 0.01 mg/kg. A slip in calculating a dose heightened with anxiety and pressure, well, it can be easy to miscalculate a dose.

Heck, we have that with levophed. The pumps calculate it differently than the order goes in the computer. So we could potentially **** it up. I have seen people screw it up before. I had the joy of explaining to a cardiologist how a new nurse in the ER misprogramed the pump and it wasn't caught right away so that rhythm was due to getting a lot more levophed.

Horseshoe, BSN, RN · Dec 2, 2015

Ten times can be a simple misplace of a decimal point. Another location used a "prime" bag of insulin to prime the tub. Well, they always printed a rate on it of 99 ml/hr. This was never to be connected to the patient. Well, one experienced nurse who should have known better connected the prime bag to the tubing and flushed it. She then had the pump set at 99 ml/hr. This was insulin. Because of the double checks, we caught it.

Wow. Thank goodness for double checks.

LVN fresno · Dec 2, 2015

Medication errors must be investigated to find ways to prevent them from being made again. Changes in medication delivery over the years have made great strides in preventing them. Punitive actions against nurses for medication errors only serves to decrease reporting of medication errors.

brandy1017, ASN, RN · Dec 3, 2015

I read through all the (somewhat catty?!) replies just to see if anyone else thought this very thing! It was all that went through my mind when I read what happened - how did the massive quantity of this medication not just scream WRONG at this woman who was allegedly used to giving it? I mean even from sheer muscle memory, not even higher level thinking, should have made this error seem obvious to such an experienced nurse, no?
What a sobering reminder of how a brief moment of inattention on our part can have such a ripple effect on patients, families, friends, coworkers, and communities. Remain vigilant friends! :)

I don't work with cacl so I don't know what it comes in, but it wouldn't surprise me if they didn't have different vials with different concentrations so it is still possible that they had a highly concentrated vial where it wouldn't take a huge amount to reach the wrong dose! Look at how many different concentrations they have for nitro, heparin, dopamine and dobutrex for instance.

Frankly I'm surprised there aren't more errors because of all the stress and constant interruptions nurses work with from alarms ringing incessantly to phones and pages and how many people coming up and interrupting us! I do believe med scanning is a great safety feature and shouldn't be bypassed. These med errors happened several years ago and I don't know if the hospitals involved had med scanning at the time.

brandy1017, ASN, RN · Dec 3, 2015

I'm torn between reading thread upon thread about too much being asked of nurses to the hard line here. From I fear the future of nursing to umpteen other ones decrying nurses being overworked, over faced, lack of patient care priorities versus hotel service and lack of breaks.
I generally have faith that everyone makes the best decision given their choices. I expect that there is way more to this story involving this nurse's competence and capacity. Who knows, maybe she has early onset or something darker. There had to be something that made them escort her out of the hospital.
I don't think it was her shock and beating herself up over the med error so much as being unemployable, but of course that is only conjecture on my part.
It's just horribly sad to see this outcome for someone with a long term stellar record and a family that she had to face.
ETA If the baby hadn't died, would we think differently about this was handled? The outcome of death and how the family feels about it keeps coming up, but I think that's irrelevant to the actions that should be taken. Actions should be based on the breach of protocol and employee assessment/record as well as systems evaluation.

It doesn't surprise me in the least that they fired her in spite of several stellar reviews. It is about CYA for the hospital in the event of a lawsuit. Of course if the baby had lived she probably would have been suspended but not fired.

People instinctively want to believe if someone is fired its because they deserved it or were a bad worker. Yet it is relatively commonplace to hear about people being fired with great reviews. The truth is any one of us could make a med error or be fired even if we are great nurses. Let's not kid ourselves! The best thing you can do to protect yourself is get along well with others, network and do a good job. If you are well liked you will be more likely not to be fired or laid off!