I made a med error

TNnursejane, BSN, RN · Apr 22, 2005

I work in Risk Management. Everyday we hear someone threatening to sue but if a lawyer takes this case, he's probably doing it pro bono! He's not going to make any thing off of it and neither is the family! Mainly because he has no case. I agree with Lawnurse: bad medicine has to lead to bad outcome and from what you've told us the error caused no harm.

Remember that no one gets up saying "I'm going to go in and kill someone today". We are all human and go into work with the best intentions. Errors happen. That's why we look at systems and processes these days rather than at the person! I'd be interested in looking at what was going on that could have contributed to you making the error. Were you distracted? There's all sort

I know that feeling though and I'm sure you felt your stomach sink to your feet when you heard about it. You break out into a cold sweat and wish you could crawl under the floor! I've been there. If you weren't concerned I'd be worried. Hang in there! You have done the right thing! We have to disclose errors to patients and families. I realize that sometimes it really isn't something that is neccessary...like giving someone and extra pain pill, etc... especially if it doesn't cause harm.

Keep us posted on what's happening!

Janie

czeafer32 · Apr 23, 2005

:crying2: I just agreed to the sympathy of all regarding your experienced . Nurses are not perfect , because of long hours of work , we are all prone to commit mistakes . And you should not really admit that you committed mistakes , that admittance gave them an idea to sue you. If you are certain that you really wrote the right meds , someone else gave them wrong medication. In the facility where i am working with d/c prescriptions should be written by the attending physician itself because they are the only one can transcribed the correct medications for the patients , and in some intances the doctors hand writing were sometimes difficult to read . If we encounter that kind of handwriting , we would call second party to read for us or else verify to the prescribing physician so we are not a sole responsible for the mistakes. We need to be extra careful in all the steps we need to do , espacially if your license as an RN will be at stake . Just imagine , you studied for so many years , spent a lot of money to finished that course , get years of experienced then suddenly with just a simple mistakes , youre life will be at mess . HOW UNFAIR IT IS FOR US ...

It amazes me that people sue too. It also amazes me that people are less than honest when they sue, this dizziness will turn into something more and big after the stories told. People also know that people settle out of court and they are going to get some money for a case they know they would loose, and maybe their hoping for that.
Good luck and I'm sorry this happened.
I'm a little confused how your SNF works. When I d/c a patient home, I write the meds down, but they still have to have a script. How does it work that you wrote the wrong med and the patient took it?

polgaras · Apr 23, 2005

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:

NO, SHE CAN'T. that is an issue at my facility. ONLY the state board of nursing can reprimand a nurse by removing her license from her. it has to be VERY serious offense to lose her license the first time she is called before the board. what she has done can NOT cause her to lose her license. if called before the board she can be placed on probation, attend classes, etc. and if they deem is serious enough she may not be allowed to practice nursing for a specified time period. the facility can report her to the state board of nursing for investigation of this med error and the proof will be on the nurse.

it sounds like she works for a wonderful company as it looked at why the error happened and took steps to prevent it from happening again. doesn't sound like the facility placed the blame on her, therefore it doesn't sound like she will be called before the state board of nursing.

i do not know if the family can call the state board and complain about this and thereby have the nurse called before the board. it is usually the office of long term care investigates allegations made by families or residents/patients. it is worth looking into.

i do know the TN state board of nursing and the AR state board of nursing takes a dim view of anyone who purports they have the authority to suspend, place on probation, or revoke a nursing license. these boards will investigate and reprimand those who do so.

xrockstheheart · Apr 23, 2005

who ever gave the med, makes the error, there is a difference between an error and a mistake, according to the board. What we haven't looked is , IS There another solution, why don't meds have a code... BP/QD or GERD/BID, CP/NTG/PRN. Psy/Dep/QD, names are great but would this help? I don't know.If a doctors writing can't be read, it is his fault and his liablility, write him up, report him to the Board of Medical Examiners, sent them a fax, he doesn't need to know. everybody has a boss.

mydesygn · Apr 24, 2005

i do not know if the family can call the state board and complain about this and thereby have the nurse called before the board. it is usually the office of long term care investigates allegations made by families or residents/patients. it is worth looking into.

In Texas, anyone can report a nurse to the BON. The BON is required to investigate the complaint. If a complaint is made and the investigator determines that it does not merit any punitive actions, the complaint is dismissed and no mention of it appears on your record. However, if after investigation, it is determined that action is required, it can be anything from reprimand, a warning, probation, to suspension or revocation of a license. It takes fairly serious error to receive action on a license and often with a lawyer, you can have charges reduced to say probation. Most issues are resolved with the investigator and you likely would not have to face the Board for a minor or several minor errors. However, what is easy is for a compaint to be made. I am sure the BON is faced with all sorts of trivial and minor complaints against nurses. The Board is there to protect the public not to discipline nurses. I have spoken with nurses who have had complaints lodged against them for minor errors and outright issues that lack merit. To me that is the most shameful thing is having someone threaten your livlihood for trivial reasons and to punish you. To prevent this, Texas has voluntary Peer Review for hospital. Each hospital has a Peer Review committee made up of practicing nurses at that institution who review any complaint and determine if it merits going to the Board. This is to prevent the BON from receiving so many complaints for minor errors. They realize that no nurse will ever be error free and frankly there would be no one to practice, if you could lose a license so easily. However, even the hospital Peer Review isn't always "fair". It is only as good as the indiviuals choosen to be part of it and they can be far more critical than any Board investigator. If the Peer Review is used to blame, criticize, and otherwise humilate the nurse than ultimately it will be seen as punitive and not reformative. You will likely find yourself losing essentially good staff because of the ease of punishment in one of these Peer Reviews.

xrockstheheart · Apr 25, 2005

In TX 3 minor errors are considered a major error, and I suppose that means 3 minor errors in a short period of time. Unless Peer Review is done right it can hurt you. But not all states have peer review. Trust me you don't want Peer REview. but if you do get pR make sure your panel is picked at random.

mydesygn · Apr 25, 2005

In TX 3 minor errors are considered a major error, and I suppose that means 3 minor errors in a short period of time. Unless Peer Review is done right it can hurt you. But not all states have peer review. Trust me you don't want Peer REview. but if you do get pR make sure your panel is picked at random.

The facility I worked at did Peer Review for 3 errors within a 1 year period. The unfortunate incident that happened with me was I have been a nurse for 14 years. Over 14 years, I had only 4 incident reports, 2 my first year as a nurse, 1 the next year and 1 the first year I worked in the PICU. I have received excellent clinical evals, nominated for nursing excellence at a large hospital, and have been a manager. Within 6 months of begininning on the new unit, I received 3 incident reports. One of the incident reports was, and I kid you not, because I had written in the IV intake for a patient but did not add the cumulative total for the 8 hours (apparently the next shift has a hard time operating a calculator). Now granted, I was perfectly ok with the other 2 incident report--neither resulted in any patient harm, but to write an incident report for something as trivial as not adding intake one day was insulting in my opinion.

What struck me is none of them either in combination or indiviually would have been reportable to the BON and yet I personally think that having Peer Review, in some ways, bypasses the manager and allows discipline to be carried out by comittee. These issues are more efffectively dealt with at a unit level and by sending someone to Peer Review, it can allow a manager to not make the changes needed on a unit since she is merely "handing it off". Anyway, I went to the Peer Review discussed the issue and everything was fine. Yet after having to deal with that , poor teamwork and an ineffective manager, I transferred from the unit.

The lesson I learned was to (1) insure that an incident report should be written for a situation that involves harm or potential harm to a patient not as a tool for one nurse "to get back at another", (2) when incident reports are used for incredbly minor issues, ultimately it elimimates near-miss reporting and threatens effective incident reporting in general, (3) if the Peer Review process is used purely to place blame and criticize and any minor issue can land you there, it will be viewed as punitive. The standard for Peer Review can't be a simple 3 strikes in a year. The bar should be fairly high to place you in Peer Review or else half the nursing staff would be there. Before you go issues should first be evaluated at a mangerial level i.e. was the person properly oriented, were they aware of the problem, were they given adequate time to correct it if it was known, how safe is their overall practice, to a certain extent how was their patient load and unit support at the time. To consider these issues is not to excuse but to insure that the indiviual is given the proper tools and practices to suceed and to put processes in place to prevent these issues from occurring with others. If this does not happen with Peer Review, it will become merely another way to treat our nurses as less then professional.

Crumbwannabe · Apr 25, 2005

the bar should be fairly high to place you in peer review or else half the nursing staff would be there. before you go issues should first be evaluated at a mangerial level i.e. was the person properly oriented, were they aware of the problem, were they given adequate time to correct it if it was known, how safe is their overall practice, to a certain extent how was their patient load and unit support at the time.

you look for trends, not isolated occurances if you seek to improve a person's performance. second off, anyone who hasn't made a med or treatment error either has an angel on their shoulder, or more likely is a damned liar.

mydesygn · Apr 25, 2005

You look for trends, not isolated occurances if you seek to improve a person's performance. Second off, anyone who hasn't made a med or treatment error either has an angel on their shoulder, or more likely is a damned liar

To me that was the saddest thing, often, depending on the manager there is no evaluation of trends. I remember one specific incident: several incident reports occured related to missed drug orders--one was someone had missed an entire page of admit orders and a patient went for 3 days without prescribed meds, I know of a second incident of where a med had been missed for 2 days. Where I have worked BEFORE, new med orders were simply never missed or at best not missed past the next shift. The reason is you never signed an order until you received the med or the label from pharmacy, you checked the label against the order and then signed the order and applied the label to the Medication Record. At this institution the med record was on a PDA bar-code scanner. When a new med was entered by pharmacy, it would show in the PDA and the nurse would check it off in the PDA indicating it was noted. You could not administer the med until this was done. Seems simple enough, however if the pharmacy never received the paper order faxed to them then it was not entered into the Medication Record. The habit of the nursing staff was to sign off the orders before they checked the PDA to see if the new order was on the patient's record. This meant no one was checking to see if the order was correctly entered by the pharmicist or if the order had been entered at all. The next shift seeing a signed order assumed that the order was complete. Anyway, the day before I left, I caught another missed med: an antibiotic was written 1700 from the previous day, order was signed off, the night nurse came by and redlined the order, I came in the very next day and I checked my charts around 9:30 and about the same time the med came up on the patient's med rec so the pharmacist must have found it, I called the doctor etc.. When I notified my manager of the incident: her response was -- "You should have checked your charts at 7:00". I stood there amazed at the level of ignorance and realized that she would find a way to blame someone even if there was no blame to be had. Needless to say, the errors continue to happen on that unit because the practice has not been addressed and the obvious trend is being ignored.

southern_rn_brat · May 1, 2005

Hi guys! I have been gone for 10 days ON MY HONEYMOON!!!!!!! I married the man of my dreams:)

I read all the responses since I have been gone. I haven't heard anything since I left for my wedding.

I wanted to respond to the questions about could I be reported to the board. I am in the PAP program in Tennessee. As soon as I found out, I called my case manager for the state and told him. Since my license is on probation, he allready reported it to the BON. so in my case, they allready know about my med error.

I also celebrated my one year sober birthday the day I got married:balloons: .

TracyB,RN, RN · May 2, 2005

Congrats on the wedding & the 1 yr anniversary.

I just wanted to add a few tidbits... Here in IL, it is NOT legal to record a conversation unless the party being recorded is aware of being recorded.

I have also worked in SNF's where the "bingo card" system was used & 3 times have been sent Zyprexa in place of Zestril. 3 different SNF's & 3 different pharmacies...Creepy, huh?

I just want to make sure I have this straight, your SNF has the nurses fill out discharge meds, the MD signs them & the nurse faxes to the pt's pharmacy of choice? Seems to me like the MD should be swallowing a tad of this error if he/she signed off on what you had written...

Crumbwannabe · May 3, 2005

... here in il, it is not legal to record a conversation unless the party being recorded is aware of being recorded.
...

illinois

illinois is, by statute, a two-party state. however, case law from both the il supreme court and various illinois appellate courts have declared illinois a one-party state in the case of private citizens (businesses and plain folks - not law enforcement). the reigning consensus is that one-party consensual recording is merely "enhanced note-taking" and since some folks have total recall without recording, how can the other party have any expectation of privacy to a conversation held with another person.

illinois requires prior consent of all participants to monitor or record a phone conversation. ill. rev. stat. ch. 38, sec. 14-2. there is no specific business telephone exception, but in general courts have found extension telephones do not constitute eavesdropping devices. criminal penalties for unlawful eavesdropping include up to three years' imprisonment or $10,000 in fines and the civil remedy provides for recovery of actual and punitive damages.

in the state of illinois it is illegal to monitor cordless phones.

federal

of the 50 states, 38, as well as the district of columbia, allow you to record a conversation to which you are a party without informing the other parties you are doing so. federal wiretap statutes also permit one-party-consent recording of telephone conversations in most circumstances. twelve states forbid the recording of private conversations without the consent of all parties. those states are california, connecticut, florida, illinois, maryland, massachusetts, michigan, montana, nevada, new hampshire, pennsylvania and washington.

the federal wiretap law, passed in 1968, permits surreptitious recording of conversations when one party consents, "unless such communication is intercepted for the purpose of committing any criminal or tortious act in violation of the constitution or laws of the united states or of any state." amendments signed into law in 1986 and 1994 expand the prohibitions to unauthorized interception of most forms of electronic communications, including satellite transmissions, cellular phone conversations, computer data transmissions and cordless phone conversations.