Coworker and Patient Harm (Title edited)

[Msmedic68w, MSN, RN]

Recently, a coworker of mine killed a patient. Not on purpose, the MAR was handwritten and he didn't see the decimal point. The patient coded and ended up needing compressions. He was taken to the ER and ended up brain dead as a result. He's a relatively new nurse. I know the state was called and they showed up, but they didn't come to my unit so I don't know what they were looking for. I've made a med error before but not one that caused injury or death, gave it at the wrong time, but it was the right med so nothing ever came from it but it was still scary and woke me up. All my coworkers have made a small med error at least once, but not one that has ever harmed anyone. What happens when a nurse kills someone? Do they lose their licence? We all know what happened but since it was so serious none of the administration will openly address it with us, like they think if they don't talk about it that it will go away. But I'm still curious to know, do they suspend your licence or do they take it? This is why I hate handwritten Mars. My coworker got fired so it's not like I can ask him, and I probably wouldn't anyways because I don't know him that well.

[llg, PhD, RN]

Please try to avoid phrases such as "My co-worker killed someone." That makes it sound like he did it on purpose and only inflames an already tragic situation.

To answer your basic question: When serious safety events happen, they are investigated -- and the actions that are taken depend on the results of that investigation. If it was a truly inadvertent mistake, the nurse might not be punished at all. If the incident was the result of purposeful negligence, criminal charges can be filed. And every possibility in between is a possibility depending upon the exact situation. There is no "one size fits all" outcome or action plan.

Hopefully, everyone involved will learn from this tragedy to prevent similar events in the future.

[Been there,done that, ASN, RN]

Sounds like an overdose of something that should have been prevented by any prudent nurse.

The fact that he was fired speaks volumes.

What will happen to his license, his livelihood and his future is up to the BON and the lawyers.

[Corey Narry, MSN, RN, NP]

We all know what happened but since it was so serious none of the administration will openly address it with us, like they think if they don't talk about it that it will go away.

They shouldn't discuss this case to you or the other staff members who had nothing to do with the case. This is a matter that should be left to the administration, the regulatory entities (BON and the state agency responsible for licensing of your facility) and this nurse's legal representative. Be careful in your own practice and refrain from discussing this with anyone, however hard it may be. Remember that this nurse likely didn't intend harm and is a second victim.

But I'm still curious to know, do they suspend your licence or do they take it? This is why I hate handwritten Mars. My coworker got fired so it's not like I can ask him, and I probably wouldn't anyways because I don't know him that well.

The case would go the usual route depending on how it was reported. If your facility filed a complaint against the nurse to the BON, then the BON will investigate the nurse's actions. The type of disciplinary action (losing license vs suspension) will depend on the outcome of the investigation. Your facility has a duty to inform the next of kin regarding what happened.

The next of kin may decide to sue and this becomes another hurdle for that nurse... a process separate from the BON investigation. In many cases, lawyers go for the big fish which can mean suing the facility for wrongdoing. Cases like these fall into "sentinel events" and facilities are bound to report such events to the state licensing board for your facility. This is where you facility can get in trouble for systems breakdowns...such as your handwritten MAR's that you rightfully mentioned isn't up to standard.

[That Guy, BSN, RN, EMT-B]

They shouldn't discuss this case to you or the other staff members who had nothing to do with the case. This is a matter that should be left to the administration, the regulatory entities (BON and the state agency responsible for licensing of your facility) and this nurse's legal representative. Be careful in your own practice and refrain from discussing this with anyone, however hard it may be. Remember that this nurse likely didn't intend harm and is a second victim.

this approach always bothered me. Once everything cools down I think it does need to be discussed. So often things happen and get brushed under the rug, but if we talk about the issues, we are less likely to make the same errors as others have. Why should we always hide the bad things that happen? They can be used as great learning tools. I know that after my medication error, I made sure to talk about it with other staff to see where I went wrong and I learned a great deal from it.

[Corey Narry, MSN, RN, NP]

this approach always bothered me. Once everything cools down I think it does need to be discussed. So often things happen and get brushed under the rug, but if we talk about the issues, we are less likely to make the same errors as others have. Why should we always hide the bad things that happen? They can be used as great learning tools. I know that after my medication error, I made sure to talk about it with other staff to see where I went wrong and I learned a great deal from it.

Let me rephrase that by saying that the facility should have a debriefing for all staff in order to answer concerns and questions, quell rumors, but not go into detail as to what happened while the investigations are going on.

This can help reassure staff yet keep things contained in the facility. Any other talk of the case should be avoided because it can get picked up by secondary sources that can cause more damage than has already occurred.

I work for a hospital that publishes a monthly "safety" newsletter by the hospital "safety" chair who is a physician. The newsletter is sent to everyone by secure email and gives short accounts of incidents that have placed patients at risk, outcomes (harm included), results of in-house investigations, and risk prevention strategies.

[Boomer MS, RN]

this approach always bothered me. Once everything cools down I think it does need to be discussed. So often things happen and get brushed under the rug, but if we talk about the issues, we are less likely to make the same errors as others have. Why should we always hide the bad things that happen? They can be used as great learning tools. I know that after my medication error, I made sure to talk about it with other staff to see where I went wrong and I learned a great deal from it.

I do agree with these comments. The reason I was told not to discuss the event was because those involved can be asked, "Have you discussed this with anyone?" Then those nurses can be deposed, thus exposing outsiders to that stress. I was deposed about a sentinel event because my name was on the chart, not because I discussed the incident or was even there the evening it happened. I found it very stressful. As far the RN, the hospital fired the nurse, but the license remained after a thorough investigation by the Board. The RN finally went back to work at a different facility. It was a blatant system's error, and we've come a long way since then.

[Been there,done that, ASN, RN]

this approach always bothered me. Once everything cools down I think it does need to be discussed. So often things happen and get brushed under the rug, but if we talk about the issues, we are less likely to make the same errors as others have. Why should we always hide the bad things that happen? They can be used as great learning tools. I know that after my medication error, I made sure to talk about it with other staff to see where I went wrong and I learned a great deal from it.

Physicians have morbidity and mortality forums. Certainly agree nurses should have the same.

[TypicalStudentNurse]

Its ok....Ive never made a med error that resulted in death but it does happen....remember you ALWAYS ALWAYS check TWICE with other nurses or even a head nurse....he may get in to trouble...he probably wont get another job now...unfortunately nurses are the most trusted of professions and when we mess up like that it shows....

[Been there,done that, ASN, RN]

Its ok....Ive never made a med error that resulted in death but it does happen....remember you ALWAYS ALWAYS check TWICE with other nurses or even a head nurse....he may get in to trouble...he probably wont get another job now...unfortunately nurses are the most trusted of professions and when we mess up like that it shows....

Actually, medication administration requires at least 5 checks. The right patient, the right drug, the right dose, the right route, and the right time. I always added for the RIGHT reason.

You will be administering many drugs that do not require another nurse to CY your A.

[Sour Lemon]

I can think of at least one occasion when a nurse was rumored to have "killed" a patient and it was no where near true. "Facts" were distorted in favor of a good story, but since I happened to have been around when the event occurred, I knew what actually happened. So be careful what you spread around with no firsthand information. Even in cases where a medication error is made, that error may or may not be the cause of the patient's death.

[canoehead, BSN, RN]

There but for dumb luck goes every one of us. I don't think he will lose his license unless there was gross negligence involved. Mistakes happen to the best of us. I imagine he will be required to do some serious reeducation and review of the circumstances surrounding the error.