I made a med error

been there · Apr 20, 2005

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 also question how the patient received the Toprol without a script. Of course dizziness is an early side effect and goes away when the med is stopped. BUT how did he also get Tegretol if it was not on the med list? The dialysis unit usually has an MD who decides which meds his patient needs....so.....who wrote the script???? A lawsuit may not occur from this but you do need to write down every conversation you had with everyone during the sequence of events just in case. No one can fault you for being honest with the dialysis unit, the family, your DON and the MD. You took immediate action when you learned of the problem and no one can question that. We have all make med errors and have learned from our mistakes so don't beat yourself up over it. Just learn from it and keep on being the responsible person you are. ( and c..y..a..)!!

Crumbwannabe · Apr 20, 2005

keep on being the responsible person you are. ( and c..y..a..)!!

They make the most marvelous little digital recorders these days that can be easily hidden on your person when you go in to see DONs and such. If you are recording a conversation and one party knows it is being recorded, it's legal. And you happen to be that one person, by law. Chances are, they are doing the same thing.

Jolie, BSN · Apr 20, 2005

They make the most marvelous little digital recorders these days that can be easily hidden on your person when you go in to see DONs and such. If you are recording a conversation and one party knows it is being recorded, it's legal. And you happen to be that one person, by law. Chances are, they are doing the same thing.

Recording laws vary from state to state.

xrockstheheart · Apr 20, 2005

medication error rate is about 25%. The hospital should inform the patients that this is so when they come into the hospital, it is a risk they take. You need to read, "Nursing as a Function of Time" , http://www.Nursewise.com and you need to go to the Medication Error people, i forget what their name is. And get your facts straight. You know I take that med and nothing happens to me. the standard of proof here is did the patient suffer any consequences, the ans is probably no. Now you know not to call the family. the biggest thing here is that you are a supervisor and you shouldn't be doing this, that's probably where they will catch you. My pharmacy send me the med, twice, once labeled with bid and the other labeled 1/2 bid. well i didn't look and took the 25mg and i was woozy for a couple of days. So I guess i made a med error on myself, the rx sure made one. Just to let you know I always mark my med sheets, with a code if there is short staffing, etc because this increases the probability of error and adverse events, like people dying.

CapeCodMermaid, RN · Apr 20, 2005

We had an order for Zestril. The card came from the pharmacy with Zestril on the label....once a day..a 30 day supply...check the card against the order...Zestril. THEN...one of the nurses who hadn't worked that side comes up to me with the card in her hand and said, "These don't look like Zestril, have the changed the formula?" I looked closely at the pills....OOPS..it was Zyprexa!! Not only did the woman get an antipsychotic she didn't need, she didn't get her Zestril! By the way, her blood pressure was perfect the whole time and she was as happy as a clam. We called the doc and told the woman what had happened...told the pharmacy of course. They said it must have been the nurses' fault...think again. I xeroxed the card which clearly showed the label and the pills. The woman was fine.

We are HUMAN...mistakes happen and everyone makes med errors. Just hope the one you make is minor and causes no harm.

ldkrn · Apr 20, 2005

We make mistakes. Fortunately, most of them don't kill people! Your physician needs immediately to take responsibility for writing her own orders completely and you need immediately to stop doing it for her.

lil_judt · Apr 21, 2005

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?

Yes.. you were honest and contacted everyone.

I made a med error and after that I made out the report, notified the next shift coming on ,monitored the patient and did all the necessary things a prudent and honest nurse does.

2 days later I am told they cannot trust me.

My gf worked at the same place and afterward I asked if he had any effects of the drug and she told me "NO" .\

I thought that being honest was just too much for the nursing home. and If I had not reported it...I would still have the job.

SNF units are crazy.

I hope you carry your own Liability Insurance. Cause the hospital may not back you unless you are well liked.

what state are you in?

kenni · Apr 21, 2005

oh my god i feel so sorry for you! you handled it very well and responsibly. i hope i never have to go through that. on a more personal note, if it were me heck yeah i'd sue! this is a serious matter, and should not be taken lightly cuz you said it was an accident and apologized for it. however, i agree with a previous post which questioned how he got the med without a valid prescription. second, (not trying to shift the blame) but i thought pharmacists were paid so much to spot such errors and call when they suspect something is wrong before filling it. from what i've been told in school so far, it is the responsibility of the nurse, the charge nurse, the physician, and the pharmacist to make sure mediction errors don't occur. they are all supposed to "double-check" eachother's work. this is why it is so easy to sue a facility because they figure somebody should have caught it.

QMA_David · Apr 21, 2005

Wow. I agree, it sounds like the patient had no harm done to them from. The dizziness can be from a number of including the dialsyis making him hypotensive. So they can't prove a specific unless the patient had a fall and hurt himself as a result of it. Thank God you did the right thing though. :)

southern_rn_brat · Apr 21, 2005

I havent heard anything yet. They keep telling me not to worry.

lol

xrockstheheart · Apr 22, 2005

medication error rate is about 25%. The hospital should inform the patients that this is so when they come into the hospital, it is a risk they take. You need to read, "Nursing as a Function of Time" , http://www.Nursewise.com and you need to go to the Medication Error people, i forget what their name is. And get your facts straight. You know I take that med and nothing happens to me. the standard of proof here is did the patient suffer any consequences, the ans is probably no. Now you know not to call the family. the biggest thing here is that you are a supervisor and you shouldn't be doing this, that's probably where they will catch you. My pharmacy send me the med, twice, once labeled with bid and the other labeled 1/2 bid. well i didn't look and took the 25mg and i was woozy for a couple of days. So I guess i made a med error on myself, the rx sure made one. Just to let you know I always mark my med sheets, with a code if there is short staffing, etc because this increases the probability of error and adverse events, like people dying.

I've been reading the post and this is what i would do

1. I would cancel my malpractice insurance.

2. i would not worry about a suit if the patient did not suffer harm

3. the medication error rate is high about 25%, you might want to check with the Institute for Safe Medication Practice.

4. You might want to report your errors to them so they can have better data, your name is protected.

5. the state board is not going to get you for a med error, they might reprimand you if someone dies

6. the best way to decrease med errors is to decrease the number of meds. meds that are not necessary in the acute care setting should not be administered. You shouldn't be wasting a nurses time with calcium for osteoperosis, when it isn't going to tx overnight. this is a tx doctors use so they can bill. you shouldn't be giving dopamine on the med floor when it doesn't work, they just do it to keep the pt in the hospital because they can bill more.

7. a pharmacist fills thousands of rx a day, that's why they get it wrong, and they get it wrong a lot

8. if you are a nurse you are going to have a med error, if you haven't had one you are not a nurse, or you are a liar

9. most med errors occur at night, and they don't get caught by the nurse that made it, it's caught by the next shift.

This just goes on and on. people. They do not cover this in school, sorry you freshman, you need to read,

mydesygn · Apr 22, 2005

I havent heard anything yet. They keep telling me not to worry.
lol

This is my personal opinion. I would respond as if the family would sue. But most importantly, I would start now gathering evidence to use toward defending yourself. (hopefully, you won't need it but you will be glad you have if you did) Make copies of your facilities policies and procedure regarding discharge process and administering medications. I would suggest that you write an objective account of what occurred that day while your memory of the incident is good. Be mindful that your written notes aren't necessarily protected from discovery in lawsuit. But if there is question, your written documentation is all you have to defend yourself. Review the patient's chart and look for anything that you omitted and that might be questioned. The reason I tell you this is that you cannot assume that you would be sued immediately, it may be a year or more before you see or hear anything about this and it becomes harder to remember any info. You can't assume that your employer won't report you to the BON, you can have the greatest relationship in the world with your immediate supervisor, but an institution will always protect themselves first and all it takes is for someone "upstairs" to become involved. People have spoke of not getting malpractice insurance -- this is my take. You are more likely to be reported to the BON than to be sued for malpractice. There are policies that will pay for a lawyer if you have to appear before the Board. However, I also understand the other side. I was named in a lawsuit once (the case was eventually dropped) but I was named because I was the patient's nurse that day. At that point, whether or not I had personal coverage was inconsequential, I had already been named. Would they have pursued me indiviually if I had personal coverage, that I don't know. But they always have to prove that your direct actions caused harm. So, coverage is an indiviual decision, most lawyers I had talked to recommend you carry it.