consequences of medication errors

fedupnurse · May 23, 2002

A lot depends on the type and severity of the error. We had a case at a hospital in my area where a doctor wrote an order for chemo for baby and he forgot to put the decimal point. I forget how many times more drug the order was for. Two pharmicists signed off on the order without questioning it and the nurse gave it. Apparently she didn't usually work Pedi Onc. The baby died. Only the nurse was fired. I guess they reprimanded the pharmacists and doc but it was the nurse that was hung out to dry.

The usual in my hospital is an incident report, call to the doc and a write up. Again it would depend on the severity. I was "spoken to" after a resident kept ordering Atropine on a patient that was coding for the fourth time in 3 or 4 hours. Had the patient been viable, he would have died from the amount of Atropine he recd. I had the audacity to question the idiot during the code by saying how much atropine has he gotten all told in the past 24 hours? There is a max amount. He said it was pe code and I corrected him. And the manager spoke to me...scary huh?

capgirl · May 23, 2002

in the nursing home where i do per diem, there is a point system for med errors. I dont know how many points can be accumulated prior to discipline, refresher, etc.

At the hospital where I work, a med error requires notification of the MD, and an incident report written for admin.

P_RN, ADN, RN · May 23, 2002

Only the nurse was fired. I guess they reprimanded the pharmacists and doc but it was the nurse that was hung out to dry.

This is why we all need malpractice insurance. No wonder no one wants to admit even the slightest of error.

Jenny P · May 23, 2002

Our incident reports are more like sentinel event reports: we document the med error; and what may have led up to the med error, and any ways that the error may have been avoided. All areas that contributed to the cause of the error are checked on the form (in fedupnurses' example, we would check that the prescriber and the pharmacy and the nurse were all at fault; and then we can suggest ways that the error could have been prevented --ex: only experienced nurses could give those drugs, the height and weight need to be on each MD order sheet, the computer could flag any drug dose that is excessive for the pts' height and weight; etc.). his system is better than putting ALL of the blame on just the nurse, because (as the example showed), it isn't always JUST the nurse who is at fault.

RN-PA, RN · May 23, 2002

Our hospital has a non-punitive policy for med errors. We do write up an incident report, call the doctor, and describe the error on the form and whether there was harm to the patient, any follow-up, etc. etc. After the report is submitted, you get a coupon for a free soda in the cafeteria. :eek: I kid you not. It's to encourage us to report errors for purposes of tracking problems in the system.

sasseynurse · May 23, 2002

Quote "Only the nurse was fired" really touched my heart. It's the nurse who carried the burden of guilt in that particular situation. Others who were involved are still going on with their lives and their paychecks.

As for me, I did recently make a medication error (as reported in the "poll section") I gave Lopressor 50mg to the wrong patient, and felt totally responsible. I immediately reported it-the doctor was notified by my supervisor and the patient suffered for it.

A report was made to my state and I waited on pins and needles for their response. They responded and my license is not being revoked at ths time, but the case will remain open.

Have I learned from this--you betcha! One of the other nurses told me that I should have just kept quiet--easy enough for someone else to say, but it took 30 seconds to make up my mind that reporting this was the only way I could live with myself.

As busy as nurses are, can we possibly be expected to know the correct dose for every medication?

My case is different because the dose was correct, the time was correct, but I simply did not know any patients on the floor and this one was not wearing any identification. I should have stopped and looked around for someone to identify the patient.

In the case of identifying dosages, that's really difficult. I thought pharmacists were supposed to recognize ranges of dosages for patients based on their age, weight, and other medications that might not be compatible with each other.

I know of one case where insulin coverage was written as 2u, 3u, ect based on the BGM readings. Somebody read the "u" as on "O" and gave 10 times the amount prescribed. Of course the patient "bottomed out" and an IV was started to counteract the sudden, unexpected drop in blood sugar. A report was never filed and fortunately the patient responded favorably to the treatment.

If someone catches a mistake, it is solely their responsibility to report and take action. The consequences are not good for the nurse if the patient has a serious, adverse reaction, as in my particular case. On the other hand, if the patient does not suffer from the mistake, the incident can be used as a learning experience for the nurse--providing there is a supportive, tolerant enviornment geared to teach rather than punish.

Don't know if this answers the question in point, but maybe it has shed some light on the simple fact that people do make mistakes. Let common sense be our guide. If it doesn't feel right, or doesn't sound right, or if we aren't sure-it is better to take a step back and question ourselves or others before taking action. Once we take action, we are ultimately responsible for whatever medicine or treatment we administer. And yes, we will be the ones held most accountable for our actions.

Thanks be to all NURSES!

oramar · May 23, 2002

No wonder you are fed up, fedupnurse, a nurse does not identify doctor's error and is fired, you did identify the error and spoke up and were reprimanded. I have worked places like that, you know no matter what you do you will be wrong. The real rule that they don't speak of is "protect the higher ups booty". It is despicable.

MollyJ · May 23, 2002

I think agencies are faced with looking accountable in the face of error and that is why the firing.

I have read about some expert in the field who is studying med errors from a systems safety perspective and I think this is hopeful. He points out that airplanes engender safety by making sure that all cock-pits are put together exactly the same and he points out that med delivery systems are sometimes to blame. One of the finest nurses I ever knew bolused KCl because our KCL bottles dose bottles were identical to the NaCL and sterile water for injection bottles. This is a prime example of system safety problems and why most units now make sure that (if they have these items) they don't look ALIKE. Her patient did fine.

I think med error safety is just simply the best reason to not have people float. Yeah, yeah, I know. Try running that argument with any supervisor. The nurse is the last "safety device" in the sytem and med safety depends on her ability to make a critical decision about the appropriateness of medicine and dose. It's hard to do that outside of your usual work area.

I also think the reports on med admin safety fail to highlight the literal millions of safely given doses annually.

Firing should not occur unless the nurse has a pattern of med safety problems AND her patient load and OT and MOT has been assessed. Time pressure and fatigue are, I think, significant co-factors for error making.

fedupnurse · May 23, 2002

Sasseynurse,

Congratulations to you for being a person of integrity! I am so proud of you for admitting the MISTAKE (because that is exactly what it was) and doing the right thing because you have a conscience.

I couldn't agree more with the med labeling, MollyJ, it is a real hazard. Not just the similarities in the color of the labels but also sometimes the way the dosage reads makes it look like it is half the dose it really is. There should be strict guidelines with these things. For crying out loud, it takes how many years for the FDA to approve a drug and they don't even mandate the simple step of unique and thorough labeling!

Oramar, that's why I stay at the hospital where I am. The nurse who was fired worked at another area hospital. If I worked there and had the audacity to question a sentinel dose of atropine I would have been canned there too. The only thing that saved my butt here is that it's a union shop and I have a huge mouth and would have gone very public.

Scary out there isn't it???

ohbet · May 23, 2002

I have a constant mantra I recite when passing meds,its the 5 rights mantra. But I still make mistakes,to err is human I guess.

catlady, BSN, RN · May 23, 2002

I was charge nurse one night when a nurse (who was already on pretty shaky ground) came to me about her patient who was becoming extremely lethargic. He was a CAPD patient who had received a couple of exchanges during the shift. Through troubleshooting, I finally figured out that the nurse was putting insulin into the bag instead of heparin. Of course, I reported the incident. The nurse had the nerve to give me a lot of attitude, when she nearly killed the patient (he eventually recovered). I don't think anything was done as a followup.

When I worked staff development, I would be asked to do education with nurses who had repeat episodes of medication errors. I think you have to look at each incident, depending on the reason for the incident, before you can decide how you're going to treat it. Is it a packaging error, a staffing shortage error, a carelessness error, a failure to consider the five rights error, a communications error, or many, many other sources. Unfortunately, most errors that I've seen are either completely ignored or completely overreacted to.