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]

"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."

it sounds as if the op not only hung her co-worker out to dry, she threw her under the bus by inciting the family and naming the person who made the error. i wouldn't have done either. it wouldn't be "putting your own license on the line" to at least give the colleague a call and find out the story. she may have put the wrong date on the patch -- we've all done that (or will do that.) she might have signed off the med immediately prior to giving it -- and then gotten interrupted by someone's fall, seizure, code or projectile emesis before she actually gave it, and while she meant to go back and give it, forgotten it. that's happened to all of us, also. or it will.

but then again, i don't know either the op or the co-worker, so i probably should not judge.

i'm a terrible person, though. i can't help but wonder if the op was lacking in compassion . . . toward her colleague.

[roser13, ASN, RN]

1) OP was instructed to call the family. That is her facility policy.

2) OP has been 'given to understand' that the nurse who made the med error has a history of incidents. He/She was not fired over this singular incident.

3) Interesting how many respondents are willing to violate reporting protocol.

[kanzi monkey]

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.

I like this approach, with the exception of dating the patch from the day before. I would just date it as is--this is the time it was given. End of story. I'd mention it to the nurse who should have changed it, but I'd sign it off myself. If no harm came to the patient, I would leave it to her/him to file the report. If harm DID come to the patient, I'd report it. And I'm sure the RN responsible would have no objection. We all make mistakes, but in the end it's about the patient, not punitive measures we may face. Honesty and reason are always the best approach--policy is generally based on this.

[kanzi monkey]

1) Interesting how many respondents are willing to violate reporting protocol.

I would not follow protocol if there was sound reason not to. Protocol does not make me a safe nurse. It establishes an excellent guideline and I adhere to it most of the time. There are situations, however, where my nursing judgment is in opposition to protocol. Using principles of nursing (not my personal feelings, opinions, beliefs, etc) I occasionally act outside of protocol. I don't know a nurse that doesn't do this.

[madwife2002, BSN, RN]

I wouldnt back date a fentanyl patch for anybody, I would just replace it and start the next 72 hours from time applied. I wouldnt report the nurse for not replacing it but I certainly would not back date it I just dont see the point.

[Ruby Vee, BSN]

i wouldnt back date a fentanyl patch for anybody, i would just replace it and start the next 72 hours from time applied. i wouldnt report the nurse for not replacing it but i certainly would not back date it i just dont see the point.

not only do i not see the point, it's dishonest. i'd do the same as you, madwife.

but i have to say, i'd give my colleague the benefit of the doubt and at least talk to her before doing anything else.

[southernbeegirl, BSN, RN]

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

that information should be private. no matter what, you should not have been privy to it. this situation sounds hinky to me.

i'm sure we've all worked with "im always right" nurse nancy that loves to report what others do wrong. not saying this is the case but it sure sounds like it might be, imo.

why not just put the darned patch on the patient and let it go?

we have a similar med error report policy but no way would one of the floor nurses be the one to call. even tho the policy doesnt specify, a med error should always be immediately reported to the supervisor. at that point, she takes over and does the notifying. at no time should the nurse making the error been identified to the family. the point of reporting it to the family is to say "we" (as in the facility, not the individual nurse) made a med error and are working to correct it.

yep, this surely sounds hinky to me.

[southernbeegirl, BSN, RN]

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.

yes! why not call her first? if you are going to take the time to call the family, then INVESTIGATE the error first! IMO, notifying the family should be the LAST thing done AFTER the investigation is complete.

i charted all day saturday as the date was august 7 because i had the date wrong. i had to go back and fix it all. what if i missed a chart? someone going to call the family and report something i did or didnt do as an error before asking me? if thats the case, then the nurse is lucky she got fired. who'd want to work for a place like that anyway.

threw her under the bus indeed, regardless of her history is my opinion.

she should have been called before calling the family.

[HM2VikingRN, RN]

Incident reports are supposed to be non-punitive and used as a means to fix systems to prevent future errors.......

[southernbeegirl, BSN, RN]

1) OP was instructed to call the family. That is her facility policy.

2) OP has been 'given to understand' that the nurse who made the med error has a history of incidents. He/She was not fired over this singular incident.

3) Interesting how many respondents are willing to violate reporting protocol.

regardless, the op should have never ever told the family who made the error!

if i were the fired one, i would contact a lawyer, get a copy of the med error policy/procedure and if it doesnt specify to notify the family of the nurse making the error..i would report her to the board and sue her. she threw her under the bus. plain/simple IMO. i would respond with legal action. oh yes, i would.

[southernbeegirl, BSN, RN]

not only do i not see the point, it's dishonest. i'd do the same as you, madwife.

but i have to say, i'd give my colleague the benefit of the doubt and at least talk to her before doing anything else.

me too on all of this!

i would never report a nurse for missing a patch without speaking to her first to find out why. even if this were common for her, i'd still insist the supervisor handle it. theres a reason for a supervisor to handle these things...they wouldnt identify the nurse. imo, that was the issue here and should be investigated.

my coworkers and i have often rewritten the dates on fentanyl patches andthe like if one gets missed.

and in this case, despite the increased bp...no harm came to the patient.

i tell ya...something stinks about this.

[HM2VikingRN, RN]

One other thing..I can think of several times when I have been med nurse and orders came up late for a new admission and the meds have been 2 hours late. I give the meds ad document "late medication order." in BCMA. I tell the truth and document it.

If anything this incident demonstrates the value of bar coded med administration....