I made a med error

Specialties Geriatric

Published

I work in a SNF facility. I am one of the nursing supervisors. About one month ago I discharged a patient to home. On the discharge meds I transcribed Tegretol as Toprol. I also listed Toprol, so he did get that med but also got Tegretol.

One week later I recvd a call from his dialysis clinic asking why he had been started on that med in our facility. When I pulled his chart from medical records I discovered that I had made the error on discharge. I immediately notified our doctor, who was in our facility on rounds, and showed her the chart. I notified my DON. I called the dialysis clinic and notified them so they could dc the med and then I called the patients sister at home and told her I had made an error.

Today my administrator recvd papers from a lawyer. they are suing us over my med error.

I remember when I talked to his sister to tell her of the error that she said he had been dizzy that week but otherwise no adverse effects of the med. But of course I am birthing a cow here.

Has this ever happened to anyone else?

I felt horrible when I found out I had made the error. There was nothing else I could do. What irks me is this sue happy mentality of the general public. Every day I see commercials on TV that say "let us sue the nursing home for you". I'm not blaming anyone but myself, *I* made the error. But why do people have to sue?

I am sorry this is happening to you. We rarely discharge anyone home, but on admissions now, I am going to recommend that we have a double check in place. I do not want to go through what you are now, nor anyone else I work with.

Being a nurse is getting scarier and scarier all the time. :(

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Yes unfortunatly Tweetys right. By the time the family has their say so, the Toprol will have caused an "abnormally low HR and caused the Pt to be dangerously lethargic for a week, which in turn caused the pt a decrease in their quaility of life". What a bunch of crap!

Good luck to you.

He was supposed to be on toprol (which was on the medication list) but I transcribed an order for toprol as tegretol. Somehow I put the toprol on the list too. So he got the right meds except for the one I added :(

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I am sorry this is happening to you. We rarely discharge anyone home, but on admissions now, I am going to recommend that we have a double check in place. I do not want to go through what you are now, nor anyone else I work with.

Being a nurse is getting scarier and scarier all the time. :(

We do the double check on admissions too but not the discharges....until today. We average about 10 admits/discharges a week.

I can't say I am not worried because I would by lying to yall and to myself. BUT I know that I did all the right things once the mistake was discovered and I took accountability for it. I dont see what else I could have done at that point. I am so thankful it wasn't a worse mistake. I could have left the Toprol off the orders as well, or written a more "serious" drug, like another cardiac drug. I am thankful that it was as it is and not worse.

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We do the double check on admissions too but not the discharges....until today. We average about 10 admits/discharges a week.

I can't say I am not worried because I would by lying to yall and to myself. BUT I know that I did all the right things once the mistake was discovered and I took accountability for it. I dont see what else I could have done at that point. I am so thankful it wasn't a worse mistake. I could have left the Toprol off the orders as well, or written a more "serious" drug, like another cardiac drug. I am thankful that it was as it is and not worse.

Sorry to learn of your current situation. As you indicated, the discharge procedure (since changed) paved the way for this kind of occurence.

If you have malpractice coverage I would strongly urge you to notify your insurance carrier at once - even though you may not have been served with a summons and complaint by the plaintiff's (patient) attorney. Any one can sue anyone at anytime for anything (subject to the statute of limitations) but whether or not they collect is another story. While dizziness is a known side effect of Tegretol, I would expect that " Bernie the Attorney" will make the allegation that his client was rendered sick, sore, lame and disabled, was unable to stoop, squat or bend, could not sit up nor take nourishment as well as a littany of all of the possible side effects that he can find in his office copy of the PDR. I would also expect that the plaintiff's attorney has a physician upon whom he can rely to further his claim.

Plaintiff's attorneys often sue everyone in sight on the theory that "let those who can, pick themselves out of the mess" but will, of course, go for the deep pockets, i.e., the medical facility and its med-mal carrier.

While most of the posters on this Board agree that the patient probably suffered little or no harm - particularly in view of the short period of time the patient was on Tegretol - none of us are prospective jurors in this case. Since this is a litigious society I would not tend to dismiss this as being a simple nuisance case worth only $100 - it warrants far more attention than that. Never underestimate your adversary! If you do not have malpractice coverage you should give consideration to discussing this with your own attorney.

Best wishes and good luck to you.

Salty

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The plaintiff also has to prove causation. He would have to prove that it was the Teg. and not any other drug that caused his dizziness. This would be extremely hard to prove in a court of law - however, this case is not going to court. No (defendant malpractice insurer) would spend tens of thousands of dollars to defend a week of dizziness, even if it was per se negligence (and I'm not saying it was). I'm not exagerating when I say tens of thousands.

there has to be:

bad medicine -> which causes -> a bad outcome

to have a sucessful suit.

Keep us posted on what happens.

When I said $100, I didn't mean that's what the settlement would be, I meant that's about what its worth in a jury award. You can actually reserach these things. For example, I once had to research how much the loss of a toe is worth in Ohio (in jury awards).

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Specializes in LTC, sub-acute, urology, gastro.
When we discharge a resident, we will fill out all the meds on the discharge sheet, but a doc needs to write or call the scripts in. Even if it is transcribed wrong on the dc instructions...a doc still needs to order it....sooo who ordered it? Sounds like someone else is involved?

:yeahthat: Same at our facility...it's an unfortunate situation & the family is being totally ridiculous. Good luck to the OP.

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A lesson to us all.

Get , it's less than $100 per year. I don't know how good it is, thankfully never needed to find out.

Walter :redbeathe

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A lesson to us all.

Get malpractice insurance, it's less than $100 per year. I don't know how good it is, thankfully never needed to find out.

Walter :redbeathe

I quit carrying malpractice years ago. I don't keep cars until they're paid off, the house is in her name prior to marraige, minimal savings, and pay the bills from my account. Other accounts are seperate or nonexistant, and no law prevents me from giving 'presents' to the family. Retirement fund is off limits even to the IRS, and the guns and jewelry and such aren't mine....

(But what about divorce?) Do I trust her? Absolutely. And even if my trust were misplaced, money is just a necessary evil to me anyhow, so long as I get my sentimental belongings like photos, childhood toys, a couple antiques. I'm not real attatched to objects, and I've started over before. If sued, my final position would not be that much different unless someone wants an old Monopoly collection, my lifelong yard jockey, and Dad's watch.

Hence the name of the post. The sharks go where the money is. They aren't going after me because they can't get blood from a turnip, after doing the investigative work of finding how much I do or don't have. Generally as I'm told when the questions start about 'do you have ?', a 'no' usually sends them looking somewhere else. I'm much less attractive than the docs and the facility. Never been sued yet, but even if I did get a judgement against me, collecting it is another matter, and they can't take my livelihood away.

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I like the way you think!

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The plaintiff also has to prove causation. He would have to prove that it was the Teg. and not any other drug that caused his dizziness. This would be extremely hard to prove in a court of law - however, this case is not going to court. No (defendant malpractice insurer) would spend tens of thousands of dollars to defend a week of dizziness, even if it was per se negligence (and I'm not saying it was). I'm not exagerating when I say tens of thousands.

there has to be:

bad medicine -> which causes -> a bad outcome

to have a sucessful suit.

Keep us posted on what happens.

When I said $100, I didn't mean that's what the settlement would be, I meant that's about what its worth in a jury award. You can actually reserach these things. For example, I once had to research how much the loss of a toe is worth in Ohio (in jury awards).

Lawnurse, I was wondering whether the nurse (southern_rn_brat) that prescribed the wrong medication can lose her license for this? I am currently in my last semester of nursing school, passing meds has been one of my biggest worries that I have for when I graduate. You work so hard to get through nursing school, and it is so easy to lose your license. What is your take on this? Thanks. :uhoh21:

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Specializes in Maternal - Child Health.
Lawnurse, I was wondering whether the nurse (southern_rn_brat) that prescribed the wrong medication can lose her license for this? I am currently in my last semester of nursing school, passing meds has been one of my biggest worries that I have for when I graduate. You work so hard to get through nursing school, and it is so easy to lose your license. What is your take on this? Thanks. :uhoh21:

One can never say for sure, but I doubt that this would result in disciplinary action that harsh. The original poster made a mistake in transcribing orders. I think it would be a huge stretch to claim that she was prescribing medication without a medical license. She acted in an appropriate manner when the error was discovered. The patient suffered no significant or lasting problems as a result of her honest mistake.

In order for action to be considered against the poster's license, the matter would have to be reported to the BON. I doubt that the poster's employer would do this, as she seems to have a good relationship with her employer, and has taken steps along with her employer to correct the situation with this patient, as well as prevent future errors. The patient, his family, and attorney certainly have the option of making a report to the BON, which would then be investigated. I doubt that would happen, as these people seem far more interested in making a quick buck than actually contributing to improved patient safety. My guess is that once they realize that there is no money to be had (due to lack of damages), they will go away.

Even if they did report the incident to the BON, I believe that the actions already taken by the poster and her employer would go a long way toward convincing the BON that this nurse is able to practice nursing safely, and thus no action against her license is warranted.

This case is a perfect example of why it is necessary to allow staff members (nurses, doctors, pharmacists, etc) to self-report errors in a non-punitive manner. By acknowledging the error and acting promptly, the nurse was able to minimize risk to her patient, as well as identify a problem with the DC paperwork that could potentially lead to future, serious errors. By correcting this "systems" error, the poster and her employer may prevent something far more serious in the future.

If she feared for her job or license, and thus failed to self-report such an error, the system might never have been changed, and someone may have suffered far greater harm in the future. That is the kind of thing that happens in facilities that handle med errors with punitive action. The same problems happen over and over because everyone is afraid to acknowledge errors and make the necessary changes to prevent them from occurring again.

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I quit carrying malpractice years ago. I don't keep cars until they're paid off, the house is in her name prior to marraige, minimal savings, and pay the bills from my account. Other accounts are seperate or nonexistant, and no law prevents me from giving 'presents' to the family. Retirement fund is off limits even to the IRS, and the guns and jewelry and such aren't mine....

(But what about divorce?) Do I trust her? Absolutely. And even if my trust were misplaced, money is just a necessary evil to me anyhow, so long as I get my sentimental belongings like photos, childhood toys, a couple antiques. I'm not real attatched to objects, and I've started over before. If sued, my final position would not be that much different unless someone wants an old Monopoly collection, my lifelong yard jockey, and Dad's watch.

Hence the name of the post. The sharks go where the money is. They aren't going after me because they can't get blood from a turnip, after doing the investigative work of finding how much I do or don't have. Generally as I'm told when the questions start about 'do you have malpractice insurance?', a 'no' usually sends them looking somewhere else. I'm much less attractive than the docs and the facility. Never been sued yet, but even if I did get a judgement against me, collecting it is another matter, and they can't take my livelihood away.

Good for you.... your what the lawyers call "judgement proof"

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