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?

[Ruby Vee, BSN]

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.

whether or not the op was trying to throw someone under the bus when she called the family and told them that "nurse nancy made a med error," and whether or not "nurse nancy" had a istory of errors, sloppiness or carelessness that may have led up to her termination, why in the world would the op tell the family which staff member made the error and then allow them to make a threat to the other nurse without passing that on?

in the first place, even if it was their facility's protocol that the family be called for all med errors, surely it wasn't their protocol that they tell the family who made the error, especially without allowing that person the opportunity to do so herself.

and if the family was so agitated that they announced they'd "take care of that," then why or why did she not share that threat with the nurse involved or with her supervisor? the outcome may have been very different if the supervisor was expecting the call from the family member and already knew the circumstances.

[rn/writer, RN]

You make some very good points.

The person who made the error should not be identified at the outset. The name may have to be disclosed if the family or someone representing them asks, but let's not paint a target on anyone's back.

Besides that, I don't think the person who made the mistake should have to be the one to contact the family at all. There is too much potential to sound defensive or to go in the opposite direction and "fall on the sword." In the untoward event that the resident has to be taken to the hospital because of a medication error or some other circumstance influenced by the nurse, she should have another nurse call the family or call on her manager or the DON and they should handle that communication. The nurse is probably already upset and does not need to be put in the line of fire. And, let's face it, it's probably better PR if a calm authority figure (as opposed to a rattled nurse who is afraid for her job) can speak to the family.

It makes sense--and is ethically and legally required--that families be notified if there is a negative outcome that requires the doc to change orders or the patient to be transported to the hospital. But, as I said before, to call over every nit-picky thing when there is no adverse effect serves no purpose other than to get everyone in a tizzy.

Good facilities take a non-punitive approach with non-habitual errors and use them to educate not only the person who made the mistake, but everyone on staff who could make that same mistake. This is so much better for all concerned. Real learning can take place when people aren't sweeping things under the rug to protect their own hindquarters or to be nice to a co-worker.

I do hope that the coworker that was fired was not let go over a single incident, but that is something we may not ever know.

[arelle68]

you did what you were supposed to do. that can often be very hard.

what i want to know is why they have you call the family. have you been given special training on how to present this information to family members? you are not the don. it sounds like a poor way to manage risk.

whoever files the incident report has to make the phone calls. that's what they told me to do.

i know nurses present information to people all the time but this sounds like a job for the people in charge (that is why they get the big bucks).

i would have liked that better.

still the mistake belongs to the other nurse not you.

i've been given to understand that this is not her only mistake.

[arelle68]

Hmm...what was the outcome with the patient...were they so hypertensive that they had a CVA d/t not getting a new patch? Seems like you could have circled the error signature, signed yourself, replaced the patch, and let the DON know...This sounds like a simple mistake, you sign for it go to grab the patch and get pulled away d/t someone falling or whatever then forget to grab the patch...if this was the worst thing this nurse has done I would feel bad as well, if the nurse had made other mistakes than this was probably the last straw as others have alluded to and they needed to go.

BP was elevated, but corrected within a couple of hours after applying the new patch.

[Scrubby]

Does anyone else here think the reason nurses don't admit to making medication errors and even covering them up is because they fear retribution? I've read many stories here about nurses losing their jobs because of making med errors and admitting to them, this doesn't tend happen in Australia if you make a med error it is treated as a system error and need for further education.

[Ruby Vee, BSN]

does anyone else here think the reason nurses don't admit to making medication errors and even covering them up is because they fear retribution? i've read many stories here about nurses losing their jobs because of making med errors and admitting to them, this doesn't tend happen in australia if you make a med error it is treated as a system error and need for further education.

it has been the same everyplace i've ever worked in the us, too. unless, of course, you're making the same error over and over again, or there's a pattern of errors. or unless you make an error, attempt to cover it up or lie about it, and then get caught.

[pinksugar]

Honestly, I don't think I would have written that up. That being said, I find it hard to believe that the nurse was fired over just this one incident you describe. You stated it was a resident, so I am assuming this is LTC (correct me if I am wrong)? Unless LTC is very different from acute care nursing, no manager I have ever had would ever fire a nurse because of one family's complaints.

I wouldn't be so quick to do a write-up in the future. We all make mistakes. The next one could be yours. Would you want to be hung out to dry by one of your co-workers?

[Jules A, MSN]

Please call the nurse first and find out what happened. Maybe she just wrote the wrong date on the patch she applied. There are many possibilities and I would surely hope that my fellow nurses would at least call me first to find out what I have to say. We all make mistakes. I'd dare anyone who has practiced for any length of time to say they never made a med error.

[roser13, ASN, RN]

"I wouldn't be so quick to do a write-up in the future. We all make mistakes. The next one could be yours. Would you want to be hung out to dry by one of your co-workers? "

It is an RN's duty to report med errors that have a real or potential impact on a patient's health. This one did.

I personally would not be willing to put my own license on the line (failure to report observed med error) over someone else's mistake. Besides, reporting an event should not, in my book, be considered to be "hanging a co-worker out to dry."

[PopeJane3rd]

Brace yourself. Everyone makes mistakes. I would've done what the other poster told you and contacted the nurse first before I went off writing reports. One of these days you will make a mistake by accident and this might happen to you where you lose your job. I have seen this happen before. I have seen people get others fired and low and behold they usually end up fired too. It's just a vicious cycle. That nurse should've just been written up.

[caliotter3]

It is looked upon as considerate to notify another nurse of a potential error before giving a write-up to the supervisors. That way you might avoid giving wrong or incomplete information, and you will be promoting team work. You would want the same treatment from your co-workers.

[pinksugar]

I personally would not be willing to put my own license on the line (failure to report observed med error) over someone else's mistake. Besides, reporting an event should not, in my book, be considered to be "hanging a co-worker out to dry."

No, it shouldn't be, but the nurse was fired.

You can do whatever you want. I wouldn't trust a nurse that would be so quick to write-up a co-worker for such a minor infraction. No harm came to the patient - a little bit of a BP elevation is not a big deal. I give my co-workers the benefit of the doubt, and I hope they would do the same for me.