I made a med error - page 4

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... Read More

  1. by   xrockstheheart
    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.
  2. by   mydesygn
    Quote from polgaras
    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.
  3. by   xrockstheheart
    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.
  4. by   mydesygn
    Quote from xrockstheheart
    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.
    Last edit by mydesygn on Apr 25, '05
  5. by   Crumbwannabe
    Quote from mydesygn
    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.
  6. by   mydesygn
    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.
    Last edit by mydesygn on Apr 25, '05
  7. by   southern_rn_brat
    Hi guys! I have been gone for 10 days ON MY HONEYMOON!!!!!!! :hatparty: 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 .
  8. by   TracyB,RN
    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...
  9. by   Crumbwannabe
    Quote from tracyb,rn
    ... here in il, it is not legal to record a conversation unless the party being recorded is aware of being recorded.
    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.

    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.
  10. by   mercyteapot
    I think the patient is probably going to come out of this with some settlement, actually. In my state, California, probably he'll get much more than he deserves. This is why your facility pays such exorbitant insurance rates, so that these claims can be settled. It is unfortunate, but it is the way things are. No sense worrying too much about the lawsuit. It could have happened to any of us.
  11. by   sassynurse78
    I am so sorry for your situation since we all make errors. But your situation did alarm me simply because where I work no doc has to sign the DC orders. It had not crossed my mind until I read this thread how dangerous this is, not to mention that I have many times not only written the DC orders (usually by what the person is already taking or what the md ordered over the phone), but also CALLED THEM INTO THE PHARMACY of the pts. choice. I do not know if the pharmacy then calls the md to verify or what. I am under the impression that most likely they do not since after I have given the orders I have been asked "And which md authorized these meds"? I beleive that from now on I will have another nurse sign the discharge orders with me and then fax them to the pharmacy, so at least I will have proof that they received the correct orders from me. I can just see this happening now: The pharmacy saying I called in the wrong med if an error is made even if I didn't.
  12. by   sbergetlvn
    I have been working in LTC since I became a nurse in 1996, as well as doing some hospital and agency nursing. I have made med errors...fortunately none of which has been "major", but each and every time I have had one I have learned from it and sure as &^%$^&* haven't done it again!

    All I have to say is that if you can show me a nurse who has NEVER made a medication error of some form or another, I will show you a nurse who hung his or her diploma on the wall and has never worked in the real world.

    NURSES are HUMAN and HUMANs can make mistakes!! One would hope that they will be minor mistakes with "no harm no foul" type outcomes, but in some instances there will be an effect on the patient.

    Hang in there thru the legal mumbo jumbo and keep a positive attitude and learn from your experience. You are right...people are too "sue happy". Those annoying commercials on TV that fish for "have you or a loved one been injured or died because of medical mistakes?" are nothing more than the legal profession drumming up business on other peoples misfortune. (yeah i know lawyers gotta make a living too, but nursing homes don't go out marketing by tripping little ol ladies for ORIF's!)
  13. by   Keysnurse2008
    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?[/quote]

    if there is no injury/ residual effect then there is nothing to worry about. i am going to play devils advocate here. when errors are made.....the effects can range from zero to permanent injury that follows them for the remainder of their life. it can alter not only their life, but their families lives forever. in those cases...then yes....absolutely yes they should receive compensation ...bc they came to the hospital/clinic/ltc center expecting to get competent nursing care and when they are the unfortunate victims to errors and that error results in lasting damage......and that error has affected how they live their life then yes.....they should be reimbursed . money cant bring back things like mental capacity/brain damage, or the ability to breathe on their own ....or really pay for their pain. but it is a step in the right direction. i mean.....how much would be " adequate " for you to be compensated if your child suffered an anoxic brain injury d/t a nsg error? there is no amt of money in the world that you would feel would be adequate...you would have much preferred your child to have received adequate care and be left intact. you wouldnt consider yourself as having hit the lotto....you would still feel the money was never enough. so...while their may be some who sue over trivial issues when their is no lasting damage.......according to every report that has been done like " to err is human"....many many people are the victims of malpractice yet very very very few ever file legal action. so...that being said...it sounds like you are saying that this pt has no lasting effects so you should have nothing to worry about ....but again.....most of the folks that do file a lawsuit for negligence etc etc ......they will never be the same again...like i said....how much would be enough to compensate you for a anoxic brain injury to your child that was caused by a nsg error? what dollar amt would be "enough"? id hazard a guess that your response would be ...." the mint doesnt print enough money that could ever compensate you for that....it isnt something you can adequately ever compensate someone for.....so ever malpractice/negligence case should really be looked at like that. not like they just hit the lottery....just my opinion.....again...it sounds like your error didnt result in any injury so that should be it....it probably wont go anywhere legally.