Fired for a medication error

[stiches]

I accidentally gave Phenergan IV instead of IM. No harm came to the patient. I told the ordering PA and my lead nurse, and filled out an incident report. Because of our computer system, there is no way to chart the change in route without charting an error. (House policy states IV route is not permitted due to risk of occurance unless it is in a larger vein than the hand or wrist. I gave it in the AC.) I was fired the next day without risk management's involvement, my manager citing safety issues and disorderly conduct.

Am I correct in assuming this might be wrongful termination? I thought incident reports were used as a quality control tool to discover and prevent errors?

[NickG, MSN, APRN]

OK, I know nothing about you and I'm sure you (and your legal team) will figure this all out in due time. I also have no opinion as to if this was/was not a wrongful termination, not my call. The one question I do have, however, is why were they ordering Phenergan IM in the first place if the patient already had an IV? From my standpoint I would have just asked "can we do it IV since X-patient already has a line?" What is the purpose of the IV if you weren't supposed to use it? Just my thoughts, hopefully this all sorts itself out for all parties involved.

[RNsRWe, ASN, RN]

OK, I know nothing about you and I'm sure you (and your legal team) will figure this all out in due time. I also have no opinion as to if this was/was not a wrongful termination, not my call. The one question I do have, however, is why were they ordering Phenergan IM in the first place if the patient already had an IV? From my standpoint I would have just asked "can we do it IV since X-patient already has a line?" What is the purpose of the IV if you weren't supposed to use it? Just my thoughts, hopefully this all sorts itself out for all parties involved.

The reason this particular med is ordered IM is because studies have shown that the risk of damaging blood vessels and surrounding tissues is much too high. An infiltrated IV, with this med, can result in necrosis of those tissues in a flash. Last hospital I worked in stopped using the IV route for it two or three years ago.

Other meds, yes, you'd probably want to see if it can be administered through the IV. But this one--- no.

[NickG, MSN, APRN]

The reason this particular med is ordered IM is because studies have shown that the risk of damaging blood vessels and surrounding tissues is much too high. An infiltrated IV, with this med, can result in necrosis of those tissues in a flash. Last hospital I worked in stopped using the IV route for it two or three years ago.

Other meds, yes, you'd probably want to see if it can be administered through the IV. But this one--- no.

Our policy is different at my facility. My original comment still stands, I would have questioned the order. Again, best of luck to the OP.

[mindlor]

Another thing to consider....

Would not the dose for an IM injection have been significantly greater than for that of an IV push?

[wooh, BSN, RN]

Not necessarily. My concern would be was it diluted ("to holy hell" as said above, hehe!)? Straight phenergan into a vein, especially a peripheral vein? You can take someone's arm off with that.

[wooh, BSN, RN]

And to the OP, if you've sought legal counsel, have you told them about posting this thread? I'm thinking that any competent attorney would be a bit unhappy about this.

[imintrouble, BSN, RN]

I wouldn't expect a new nurse to be fired for one med error. It stinks that you were. Especially when you had the integrity to admit the error in the first place. I give you major points for admitting the mistake.

Good luck.

[imintrouble, BSN, RN]

To mindlor:

I've been a nurse for awhile, and the dose is the same.

[hope3456, ASN, RN]

i was recently fired over a minor documentation error (6 months ago) but got a much better job offer the next day. couldnt believe my luck. I was not given a chance to give my side of the issue.

I worked m/s 2-3 yrs ago in a rural hospital and I 'pushed' phenergan (diluted in 10 cc saline) with no adverse effects many many times - as did all the other rn's. There were a few extreme situations in the literature which is why they started diluting it and piggybacking it and advising against IV push but it used to commonly given via this route.

I admit I have made errors (none fatal thank God) but my question is.....everytime I have to work short staffed should that be considered an 'error' on the part of the nurse mgr?? Some errors are caused because of a faulty system. Unfrtunately, the nurse takes the beating, we are an easy target. Investigating 'why' the error was made might be too much work on part of mgmt and god forbid they need to implement systemic changes so the same error doesnt happen again

Kudos to the OP for hiring a lawyer - this issue does need to be addressed in the nursing profession. You were honest about what happened and u shouldnt be retaiated against.

oh and btw - a few weeks ago I called the facility in which i got fired from - stating I was going to be moving to the area and wondered if they had any openings. "Oh yes yes. Can I send u an application? We have openings on all shifts!" states the receptionist.

[Esme12, ASN, BSN, RN]

to mindlor:

i've been a nurse for awhile, and the dose is the same.

25mg of phenergan is the max iv dose and needs to be administered over 10-15 min. dosages should start at 6.25mg iv and increase if necessary. this is a very caustic drug to the veins and despite precautions some facilities have removed it from their formularies.

severe tissue damage can occur regardless of the route of parenteral administration, although intravenous and inadvertent intra-arterial or subcutaneous administration results in more significant complications, including: burning, erythema, pain, swelling, severe spasm of vessels, thrombophlebitis, venous thrombosis, phlebitis, nerve damage, paralysis, abscess, tissue necrosis, and gangrene. sometimes surgical intervention has been required, including fasciotomy, skin graft, and even amputation.

safe practice recommendations: along with the manufacturer recommendations, the following strategies should be considered to prevent or minimize tissue damage when giving iv promethazine.

limit concentration. since 25 mg/ml is the highest concentration of promethazine that can be given iv, stock only this concentration (not the 50 mg/ml concentration).

limit the dose. consider 6.25 to 12.5 mg of promethazine as the starting iv dose, especially for elderly patients. hospitals have reported that these smaller doses have proven quite effective.

dilute the drug. require further dilution of the 25 mg/ml strength to reduce vesicant effects and enable slow administration. for example, dilute the drug in 10 to 20 ml of normal saline if it will be administered via a running iv, or prepare the medication in mini bags containing normal saline if there is time for pharmacy to dispense them as needed for individual patients.

use large patent veins. give the medication only through a large-bore vein (preferably via a central venous access site, but absolutely no hand or wrist veins). check patency of the access site before administration. note: according to the package insert, aspiration of dark blood does not preclude intra-arterial placement of the needle because blood can become discolored upon contact with promethazine. use of syringes with rigid plungers or small bore needles might obscure typical arterial backflow if this is relied upon alone.

inject into the furthest port. administer iv promethazine through a running iv line at the port furthest from the patient's vein.

administer slowly. consider administering iv promethazine over 10-15 minutes.

create alerts. build an alert to appear on computer-generated medication administration records (mars), electronic mars, and on automated dispensing cabinet screens for nurses to view each time they access and administer a dose of promethazine, reminding them that the drug is a vesicant and should be diluted and administered slowly through a running iv.

treat. the manufacturer notes there is no proven successful management of unintentional intra-arterial injection or perivascular extravasation. however, sympathetic block and heparinization have been employed during acute management of promethazine extravasation.

use alternatives. consider safer alternatives that can be used for the various conditions treated with iv promethazine.

remove from formulary. some hospitals that have continued to experience adverse outcomes despite safety measures have removed promethazine from their formulary or banned its iv use.

promethazine - intravenous (iv) dilution

[Esme12, ASN, BSN, RN]

OP. YOU made an error....in and of itself is probably not grounds to fire you.....however, most places are "at will" employers and the can fire you for whatever they wish.

At-will employment is a doctrine of American law that defines an employment relationship in which either party can break the relationship with no liability, provided there was no express contract for a definite term governing the employment relationship and that the employer does not belong to a collective bargaining group (i.e., has not recognized a union). Under this legal doctrine: any hiring is presumed to be "at will"; that is, the employer is free to discharge individuals "for good cause, or bad cause, or no cause at all," and the employee is equally free to quit, strike, or otherwise cease work.

http://www.bls.gov/opub/mlr/2001/01/art1full.pdf

An at-will employee can be fired at any time, for any reason (except for a few illegal reasons, spelled out below). If the employer decides to let you go, that's the end of your job--and you have very limited legal rights to fight your termination.If you are employed at will, your employer does not need good cause to fire you. In every state but Montana (which protects employees who have completed an initial "probationary period" from being fired without cause), employers are free to adopt at-will employment policies, and many of them have. In fact, unless your employer gives some clear indication that it will only fire employees for good cause, the law presumes that you are employed at will.What was wrongful? You made a mistake, you were fired.

Your employer is subject to federal and state laws prohibiting job discrimination (as all but the smallest employers are), you cannot be fired because of certain characteristics, such as your race, religion, or gender. (For more information on discrimination, see Nolo's articles on Your Rights Against Discrimination and Harassment.) Similarly, you cannot be fired because you have complained about illegal activity, about discrimination or harassment, or about health and safety violations in the workplace (see Nolo's article Assert Your Safety Rights Without Fear of Retaliation). And you cannot be fired for exercising a variety of legal rights, including the right to take family and medical leave, to take leave to serve in the military, or to take time off work to vote or serve on a jury.

Employment At Will: What Does It Mean? | Nolo.com

But laws vary somewhat state to state. Did you have a contract? Most disciplinary policies at hospitals state "subject to disciplinary action up to and including termination". You can hire a lawyer....they are expensive and they do not usually do pro-bono or consignment agreements. From what you have posted I do not see what was wrongful and they don't need to consult "risk management" in order to fire you. Even if you have never made a mistake before and are the epitomy of a stellar employee.....you made a mistake and they feel it was severe enough to terminate your employment, unfortunately it's their choice. I am curious as to what they felt was disorderly conduct.

I am sorry you are going through this :hug: and I wish you luck. And if you hired a lawyer....I'd stop posting on public boards.

[deann52]

In L&D we used IV phenergan all the time, good patent vein, highest port over 2 min.

In Kaiser it would take a whole lot more than a documented, reported, followed up medication error. We can't even be written up for med errors unless it is obvious neglect or intent. A reporting form is done that does not have your name on it and you may be given a QA questionairre to fill out (why did it happen, how could you prevent it in the future, etc.) They did this to get nurse to admit the mistake so we could fix it.

If you are so worried about getting fired then no one would admit the mistake. The OP didn't have to tell anyone about the mistake. Think about it, IV vs IM? With no witnesses? She didn't have to admit it, but she thought the process would protect her and it didn't. Shame on them.