Another nurse got fired because of me.

[arelle68]

I discovered a pretty serious medication error last week, (Signed, but not given. Involving blood pressure.) and had to file an incident report. I called the resident's family per protocol. The resident's daughter told me something like, "Well, I'll take care of it. I can guarantee you this won't happen again!" Apparently she did, because I got to work today, and found out that the nurse had been fired. It's a tough economy, and I hate to see anyone lose their job right now. I know I had to do what I did, but I feel bad for this nurse. Anyone can forget to do something sometimes. How am I supposed to feel about this?

[K.P.A.]

That could be serious, except that in the case of a patch, the nurse would see the new one with the current date and know that the change had already taken place. Worst case, the new patch would be removed and an even newer one would replace it.

NO! Worst case is one nurse applies the patch and an hour later a different nurse applies another...

[flashpoint]

I'm sure I have signed for meds that I didn't give...I'm sure a lot of us have. How easy is it to be flipping through MARs and TARs at the end of the shift to make sure all your boxes are filled in, see a blank, and sign it, not even aware that you missed the drug? Sometimes things get so hairy that you simply miss something...it shouldn't happen, but it does. Unfortunately, this nurse missed something that someone can prove she missed.

As far as notifying the family...where I work, it used to be protocol to noify them...now it is not unless there are effects that require intervention other than something routine...if a resident's B/P goes up and we can fix it with what we have, we don't notify...if we have to get new orders...we notify. Actually the DON notifies...charge nurses would say the wrong things and end up getting the facility sued or shut down or something.

It sounds to me as if you did nothing wrong...as long as you followed protocol, you have nothing to feel guilty or worried about.

[Ruby Vee, BSN]

i know i'll probably get excoriated for admitting this, but i have signed for meds i didn't give. it's not a good practice, but i remember once going into a room fully intending to give all the meds in my hand. gave the po meds and the nitroglycerine paste, but just as i was getting ready to give the heparin injection, the patient in the next bed had a run of vt. forgot all about the heparin as i went to shock the patient. later, when i went back to the mar to sign off my meds, i remembered drawing up the heparin, so i signed that off too. it was only the next day, when i saw that syringe still lying on the nurse server that i remembered i hadn't given it.

i've put medication patches on a patient with yesterday's date, too, because i'm so brain dead i've forgotten what date it is. (if any one of you reading this claims you've never done such a thing, i'm sure you will one day.)

although i would never advocate dishonesty, there may be a very good reason why that catapres patch got signed off but not given.

[mykidzmom]

i think--i hope-- that there must have been a long list of errors your terminated co-worker racked up. the error she made was one probably just about everyone has made. there are 2 reasons i hope this incident was "the straw." it is an often discussed subject, the handling of med errors and near misses. the generally accepted view is to take a non punitive approach to errors. the first reason is YOU. how likely are you to report another error that you find or make? you are obviously sick over this incident and you don't want to be (or feel you are) the cause of a co-workers termination. although you did the right thing, YOU ABSOLUTELY DID THE RIGHT THING, you will understandably question what you should do when it happens in the future. the second reason is everyone else you work with. if one med error is punishable, then out of fear, nurses will be less likely to report their own errors at the potential detriment of the patient. i knew a nurse whose previous job gave them movie tickets if they reported their own med error or near miss. not habitually, of course. that is a separate issue. the idea was to create an environment to be able to solve system problems by being able to collect accurate data.

i once made a serious med error. i couldn't believe it. i called the doc, wrote it up, did the proper thing, the patient had no ill effects thank goodness. then, i got written up by my manager for it. and i am not typically a very strong self advocate--i can get pushed around or taken advantage of. however, in this case i went to HR and the VP of nursing to insist that disciplinary document be removed from my records because no one is supposed to be disciplined for a non habitual error. i felt it was a very big deal. the point is, i really doubt you did this. please please don't lose any sleep over this. you will run into finding co-workers errors often--usually "minor" relatively speaking. you did not get her fired. i don't think you should have called the family. someone higher up the food chain shoulda done that.

[Medic/Nurse, BSN, RN]

I think there is something "missing" here.

I have been in many facilities and I have NEVER seen any protocol that involves a medication incident, that caused no harm (come on - was the BP wicked high, some other symptoms?) and was called to a patients family (that sure seemed to stir them up into a frenzy no less - they were even leveling the threat with you kind reported OP that action would be coming..) as a routine course of action.

I am also a bit perplexed by all the responses here that make an assumptive "leap", and tend to rationalize that this nurse (that the OP feels so bad about) must have been error-ridden and surely was not fired just because of the OP, but there must have been a pattern of errors.

Folks - something just does not sound right.

To the OP - I am confused as to this policy. Is this the official policy of all errors to call to the family? If any and all "errors" are called - I'd guess that there would be days that nothing else could get done except "reporting". If a dressing change is missed/late, what if ensure is refused, what if the resident spits out a pill or whatever. Now, I understand that missing a medication is serious and even if no harm was done - it is still an error - but, I'm confused as to how this was "reported" to the family.

A difference in:

Ms. Smith, this is Jane at the nursing facility. By policy I have to call and let you know that your _____ did not get a medicine that was due yesterday. It was for her blood pressure and although her BP was slightly elevated, she seems fine and the medication has been given and we will take special care to watch her.

Other explanations could be far more inciting to the family. This would be a case where how it is presented may be more important that the fact it was presented. No accusations - just saying.

Most all of us know that some families that can be difficult - and while I do not ever advise withholding the truth - I do advise being kind and considerate of my fellow staffers. Heck, you may be one to make the next mistake. It seems like this family sure got riled up.

Like the awesome Ruby Vee and some of the other amazing nurses - I too have made an error such as this type. Anyone that does this long enough will make a mistake. Like all mistakes I follow the same pattern.

1. Take care of patient. Mitigate the error's effects.

2. Admit the error and be responsible.

I guess to calm your feeling of blame - ask yourself if you had made the error - would you have wanted anyone to handle it the way you did? If you have no guilt over your role in reporting (which was technically right) or how you reported it and to whom - then you are off the proverbial hook. However, if looking back you had any role in "expanding" the consequences - - - then well - I guess what goes around will someday come around.

We all make mistakes. I always take care of a patient first and then do anything/everything else. I may have called this nurse when I found the error - a catapress patch - heck, this could have been pulled off by the patient, got stuck on clothing or something like that. Maybe there was some explanation other than "omission". Anyway, I'll stop here - you can't unring the bell. As I do not know many specifics - and I try not to judge - I likewise, do not try justify any actions - you seem to be feeling bad for this fellow nurse - but this isn't anything that anyone can do to undo what is done. Maybe the nurse had it coming - you are in a spot to know if this was great nurse in a bad situation (seems like the punishment and crime do not jive to me!) or a nurse that was a disaster waiting to happen. It also goes without saying that I have seem some really bad behaviors from some nurses toward other nurses - many without any reason or justification, but all unprofessional. Not saying that is your case - but, it sure doesn't seem like the error alone should have been career ending.

Maybe this issue got way too much traction - sure, it was slip - but from the outcome a nurse was "under the bus" - I guess how he/she got there is key - lying in the road waiting to be run over is way different from being thrown under the bus.

Practice SAFE!

[rn/writer, RN]

Maybe this issue got way too much traction - sure, it was slip - but from the outcome a nurse was thrown under the bus.

You're coming down on those of us who said there may have been other errors leading to this decision because we appeared to make an assumption. This statement seems just as much an assumption.

I was saying that I thought firing over this one incident would be an overreaction, therefore, one would hope that there was something a little more substantial behind the decision.

To state that the nurse was thrown under the bus is to look only at the result and not what lead up to it.

None of us is in a position to evaluate this situation accurately as we have limited information. The OP herself does not know if this nurse had been written up before. Maybe she was on probation for prior problems. Assumptions, pro or con, are only speculation.

I do agree with those who believe that calls should be made to family only if there are adverse effects. They deserve to know if their relative is having a problem. But to call them if an i was not dotted or if it was dotted late, that seems to be unnecessarily alarming and a huge waste of employee time.

[ChristyRN2009]

I'm glad I'm not the only one who sees a problem with punitive reactions to med errors. If I were you op I would find out if possible if the nurse was fired solely for this reason. If he/she was then WATCH YOUR BACK! It could be you next. Id also recommend getting involved with policy and seeing about changing it if it truly is policy to call the family when a med error occurs. At the very least upper management needs to make those calls. That just seems to be opening your facility up for lawsuits. Sheesh.

[ktwlpn, LPN]

I think there is something "missing" here.

I have been in many facilities and I have NEVER seen any protocol that involves a medication incident, that caused no harm (come on - was the BP wicked high, some other symptoms?) and was called to a patients family (that sure seemed to stir them up into a frenzy no less - they were even leveling the threat with you kind reported OP that action would be coming..) as a routine course of action.

!

I'm in LTC-our policy states that we must always notify the physician and the first contact of ANY med error regardless of the condition of the resident and the nature of the incident..-.Our policy also states that we don't reveal the identity of the staff member/members involved.That makes incidents like this a rarity.We have a progressive disciplinary procedure.You don't get fired for ONE mistake..THat leads me to belive that either this nurse had a documented pattern of errors or the facilty gave in to threats from a troublesome family-and who wants to work there if that happened?

[ReemBZN]

I encountered similar situation before. Nurse who was working the day before was supposed to change fentanyl patch on this pt and she forgot to do it. when i found out that the next day,i changed it for her and dated as of the day before. since she is a regular pm nurse on my floor, i let her know what i did when she came in that afternoon, and she signed for it. end of story.I mean..im not trying to save anybody's a** but nobody's really perfect afterall. I could make same mistake..anyway it seems a little harsh punishment for what happen in OP.

[Batman24]

The OP better be careful because if this is how med errors are handled where she works she could be next to go. The whole thing seems a little extreme under the circumctances. The patient suffered no ill effects and it was a situation that could have been rectified. I also don't think nurses should be calling families on other nurses. Management should be making those calls not the people making and finding the errors.

[Medic/Nurse, BSN, RN]

you're coming down on those of us who said there may have been other errors leading to this decision because we appeared to make an assumption. this statement seems just as much an assumption.

i was saying that i thought firing over this one incident would be an overreaction, therefore, one would hope that there was something a little more substantial behind the decision.

to state that the nurse was thrown under the bus is to look only at the result and not what lead up to it.

maybe this issue got way too much traction - sure, it was slip - but from the outcome a nurse was "under the bus" - i guess how he/she got there is key - lying in the road waiting to be run over is way different from being thrown under the bus.

practice safe!

please read what i posted about being under the bus and do not take editing liberties with a post and after editing use my words in a way that they were not intended.

i did outline the finer points of being under the bus.

thanks.

[rn/writer, RN]

Maybe this issue got way too much traction - sure, it was slip - but from the outcome a nurse was thrown under the bus.

This is the last line of what you originally wrote. I cut and pasted it from your post, so I'm sure that's what was there when I responded.

You edited your post to add this part after I quoted the original--

- I guess how he/she got there is key - lying in the road waiting to be run over is way different from being thrown under the bus.

Regarding your admonition to me--

Please read what I posted about being under the bus and DO NOT TAKE EDITING LIBERTIES with a post and after editing use my words in a way that they were not intended.

--it may be that you were editing while I was responding and our efforts crossed in transit, but I did not take editing liberties with your original post. As someone who values the written word, I really try not to do that.

This appears to be a simple misunderstanding. You edited the original message that I quoted after I quoted it. While that's certainly your prerogative, it would have been nice if you had taken that into account before "shouting" at me about something that turned out not to be accurate (that I took liberties with your words).

Hope we can put this behind us and move on.