HUGE mistake

chasinRT · Oct 30, 2017

I count scheduled medications when they come in; in our district kids are allowed to bring meds and turn them in as soon as they arrive. If a kid brings a med, I count it with office staff cosigning. I then reconcile at the end of every week, making sure the number of pills given reconciles with how many are left. If a scheduled meds get dropped, I waste it with a witness. I don't count any other meds.

grammy1 · Oct 30, 2017

If a scheduled meds get dropped, I waste it with a witness. I don't count any other meds.

Last week I was giving an adderall to a student, it was his last one. Yep, he dropped it. I can't believe what I did, I yelled, "Five second rule," he quickly picked it up, wiped it off, and took it. He was probably the one student who needed it more than anyone. I hated to see him go without it, and it just came out of my mouth instinctively. Afterward, I couldn't believe that I did it, so I called his mom and apologetically explained what happened. She just laughed and said they believe in the five second rule at their house too.

We are required to count ALL meds when the come in, including OTCs. I no longer accept any OTC's unless they are sealed. Nothing is counted again.

JenTheSchoolRN, BSN, RN · Oct 31, 2017

Last week I was giving an adderall to a student, it was his last one. Yep, he dropped it. I can't believe what I did, I yelled, "Five second rule," he quickly picked it up, wiped it off, and took it. He was probably the one student who needed it more than anyone. I hated to see him go without it, and it just came out of my mouth instinctively. Afterward, I couldn't believe that I did it, so I called his mom and apologetically explained what happened. She just laughed and said they believe in the five second rule at their house too.
We are required to count ALL meds when the come in, including OTCs. I no longer accept any OTC's unless they are sealed. Nothing is counted again.

Oh, grammy1, don't feel bad because this is pretty exactly the same story that happened to me once! After it happened, I was like, what did I just say? I called mom and we both laughed and laughed. Mom was awesome and actually very glad her child still got the med because that kid was one that if he missed a dose got very on track at school.

Amethya · Oct 31, 2017

I think you should be counting ANY narcotics that come in, with whoever delivers them.

Well what's on the amount on the bottle, I assume that's how much it's in it. But I'll be doing that from now on.

OldDude · Oct 31, 2017

Hey, how about this idea...if there is no count, and you don't know how many you have to start with, you can never be short! :up:

Patient Safety Columnist / Educator · Nov 3, 2017

It takes a huge amount of courage to admit you are wrong. I admire you and support you. It's smart to reach out and find support - shame and loss of confidence often accompany error; you can combat that by talking to trusted co-workers and friends. I hope you reported the error - the only way we can prevent future error is to examine the systems in place that allowed the error to occur in the first place. I know it's hard to report, but patient safety has to come first. Being open and transparent is how we make the world a better place.

OyWithThePoodles, RN · Nov 3, 2017

Well what's on the amount on the bottle, I assume that's how much it's in it. But I'll be doing that from now on.

The reason this could be dangerous is because a lot of times these kiddos take the medicine several times a day. Pharmacy will fill the rx for how much total medicine they need all day, not just the school dose. So a 30 day supply of a TID med would be 90 pills, but Johnny only gets it once a day at school, so his mom only gives you 30. Bottle may say 90, but that's not how many you have. Most pharmacies just reprint the label they put on the original bottle for the school bottle, which would have the 90 count.

I hope that made sense...