I need opinions on med error issue

[~Katniss~]

I work nights at a long term facility. I have for six years since nursing school. The beginning of this year the company was bought and we have a new DON and now some of her former co-workers have joined us . This year I have been floating between two assignments on the our second floor. Medicare assignment and opposite assignment on the same unit. This particular month I was mostly on the B assignment the first half of the month then was alternating between both. We are not computerized and we do the MAR and change over the old fashioned way. Each nurse is to do two MAR leading up to change over night but February was a short month so I had three to do on my night shift. I had a very busy night and was told in inservice in the past that when doing mar we are to check the new mar to the old mar and check the chart for orders in question and from the day we are doing the Mar, since everyday before that the night shift should be doing their chart checks for each day. Apparently there was a med error in the middle of the month on a MAR I did on the 26th. The pt had an order for 30mg of Restoril and there was a new order for 15mg. The nurse that noted the 15mg on the mar put it on but did not D/c the 30. both were on the Mar for three days until the usual 3-11 nurse came on and saw it and called the doctor to see which one she wanted to go with. Well she said" discontinue the 15 and keep the 30. I forgot she already had an order for 30mg. The nurse wrote an order "Discontinue previous restoril order for 15mg. So she d/c it on the Mar and kept the 30mg. That was around the 23rd. When I did the MAR on the 26th I saw the 3o as active and the 15 as discontinued. I made sure this was also on the next months MAR.

I was told the med error was that when the 15 was discontinued a new order should have been written for the 30mg by the 3-11 nurse. This was on the 24th and I checked the MARs on the 26th. Since we have a regular assignment busy with 30pt we are not required to check back in the month for errors. That is supposed to be caught by the night nurse each night doing chart checks. I was the only one that got written up and suspended for this. Not the nurses who put the 15mg on the mar and forgot to discontinue the 30, not the night nurse doing chart check that night who should have caught it right then. Not the 3-11 nurse who could have written the new order for the 3o mg when she wrote to discontinue the 15mg. So the new DON decides it is my fault because I checked the new mar on the 26th and I was unaware of the med error because it was not my responsibility to check back in the month.

Also this DON when she had me in the office held up a cup of pills with a date on it and said it was found at the bedside of a resident who fell back to sleep and did not take it. I said it could not be me because I never leave meds I always watch. I asked her the date and it was a date I was working on the opposite assignment. Then she snapped at me and pulled out a copy of a MAR that had a lab that was initialed for the 24th and said to me" this is not your initial??" I said I was on the other assignment on that date. Everything on the other assignment is signed by me so I can prove it. Apparently another nurse has an initial that looks like mine. So I told her that but she still wrote me up and suspended me for three days. I took it because I was afraid to speak up that I would be fired at that moment, because after telling her I was not on that assignment that night she held the cup of pills up and said " I can fire you for just this right now but I am giving you one more chance. " I said again it was not me. Being afraid to speak up that I would be canned right then and I can not afford that. I just left. I went out right then to find another job. By the next day I had three offers and by two days I was hired by another place. I just cant stay at a place with that going on. There is a paper mess. I don't want to get caught up in other peoples mistakes. I have a DON that is blaming me and not even holding the people that failed responsible. When I came back to work after my suspension I found out that one nurse was brought in the office and told she should have written the order for the 30mg. the other nurse also was told you failed to discontinue the 30 mg when putting the 15 mg on. The night nurse that could and was responsible for catching this never was told anything. The nurse that missed the lab on the 24th was never told anything. I even copied the assignment sheet showing I was on the other assignment that night. This DON just seemed like she was having job in telling me I am a bad nurse and she could fire me at any time and will be checking all my work. It wasn't even me. I put in my resignation and worked out my two week notice. I found out the administrator that started this year is leaving this week also. I get the response " it happens a lot." I just need an opinion on all this. I feel like I have been bullied or like a scapegoat. everyone that knows me knows I am a good nurse and very careful when checking charts and orders when I do my night chart check. I have a busy assirnment and 30 pts to take care of some are acute care. I was only responsible for checking from the date I did that MAR. I feel I have been wronged but I feel I should just go quietly because if I make an issue of this there would be some retaliation by this lady. she doesn't even listen to any thing her staff tries to tell her to make things better. just disappointed

[SWM2009]

If it were me I would just let it go. I don't see any good coming out of confronting that administrator at this point. Leave it all behind and embrace your new job.

[Meriwhen, ASN, BSN, MSN, RN]

I agree. You've nothing to really gain by pressing the matter, especially since you've gotten out of Dodge. Focus on your new position and congratulations!

[~Katniss~]

That is how I feel. I didn't really say much. I just went out of the meeting where she suspended me and put my effort to finding another position. Just am surprised and wonder why she would do this when I told her and showed her I was not on that assignment. I am trying to be perceived as a confident person and not just nice and sweet. I have taken some bullying in the past and just ignored the attitudes and did my job. I just needed thoughts on what happened. Is this kind of thing going on a lot or is things pretty fair mostly out there.

[caliotter3]

The medicine in a cup that you supposedly "left at the bedside" is a standard trick. The DON refusing to listen to reason because she had already tried and condemned you in her mind is an everyday occurrence for many. You took swift and appropriate action by finding a new job and getting out of there. Now, congratulate yourself for dodging that bullet and remain alert at your new job. The old one does not merit any more worry on your part.

[~Katniss~]

The medicine in a cup that you supposedly "left at the bedside" is a standard trick. The DON refusing to listen to reason because she had already tried and condemned you in her mind is an everyday occurrence for many. You took swift and appropriate action by finding a new job and getting out of there. Now, congratulate yourself for dodging that bullet and remain alert at your new job. The old one does not merit any more worry on your part.

Everyday occurrence? I don't think I would want to work in such a hostile environment. Thank you for your input. Full speed ahead.

[caliotter3]

There are lots of managers across the nation that have their own way of doing things that does not always involve a degree of fairness. Sometimes you will hear of these people through the nursing grapevine, and know to avoid them if possible.

[nursel56]

We've had a run of posts describing managers that bring to mind something out of a Dickens novel the way they berate people and set them up to fail. I wouldn't do another thing, but consider yourself lucky to be one of the first to get out of there.

All the best to you in your new position!

[~Katniss~]

Thank you for that advice. I already see more problems as I am on my way out. New nurse complaining about missing orders that were written on lab sheets by doctors in an folder marked for 11-7 to file and check the orders. The whole folder is missing. I spend more time trying to find things. I think the DON takes things our of charts into her office. Cant go to check last months MAR in the chart for reference because it is missing and with the DON supposedly she is checking for holes and who knows what but that is fine but maybe we need them. As for the cup of pill trick. Another nurse told me this morning they tried to get her on that but she never works the shift the DON accused her of doing it on. I k now I need to move on and forget but I just needed to vent about what happened. I had my choice of three positions. I chose one farther from my home because I felt the DON would be fair and supportive.

[~Katniss~]

We've had a run of posts describing managers that bring to mind something out of a Dickens novel the way they berate people and set them up to fail. I wouldn't do another thing, but consider yourself lucky to be one of the first to get out of there.

All the best to you in your new position!

Thanks

[GuEsT78]

The others are right. Congratulate yourself on making a successful exit from a bad situation that was likely to grow far worse. I also admire your courage standing up for yourself.

When I faced similarly absurd charges at differing times from two different head nurses at a major hospital, I took the easy way out. I played stupid. I figured, probably correctly, that any protest I made would come to nothing. I was also getting less flack than most of those I was working with, so I didn't want to make myself an even more visible target. Yeah, kinda gutless, but I had other priorities than battling a bureaucracy. I was caring for children with cancer.

In one case, I didn't yet know the facts that exonerated me. In the other case, all I could think of doing was telling that head nurse she was a "blithering idiot." The patient, a teen boy, was getting a particularly nasty chemotherapy drug called cisplatin. I knew it well and never made a mistake with that 'drug from hell.' I'd followed orders to the letter and there were no complications. I'd not only done nothing wrong. I'd given exemplary care.

I suspect in the latter case that it was the utter absurdity of her charges that reassured me. "If that's all you can throw at me after the months I've worked on this unit," I thought, "then I must be doing quite good work."

Like your situation, the nursing administration was seriously out of kilter. Others were getting the same ill-treatment and worse. Just weeks after I left to go back to school, there was a mass exodus from the hospital, with some 20% of the floor nurses leaving and the word went out in the nursing community "don't work there." Why? Because like you the nurses felt they had no alternative but to leave.

That does not have to be. Good systems have ways to bypass the formal administrative structure and get a proper hearing for complaints. You can hardly find a job that's more high-stress than a U.S. Navy ballistic missile submarine. They're deep underwater with scant contact with the outside world for three months and operate under enormous tension. To keep up morale, the subs have someone in a position called COB—Chief of Boat—who mediates issues between the crew and officers. He's an enlisted man whose job is to tell the captain, to his face, that he is wrong. If you've seen the movie, Crimson Tide, that's precisely what the COB does in the movie's climatic scene.

Hospital nursing needs something similar, a nursing position that's outside the normal administrative structure and tasked with independently accessing nursing morale and the adequacy of their on-going training. A nurse who takes a complaint to such a person can be assured that she will be heard without her identity being revealed.

I've almost finished a book describing what that position would be like and why it is needed. You can find it on Wattpad.com, a website that offers previews of upcoming books. Just look for it by title, Senior Nursing Mentor.

[No Stars In My Eyes]

Sometimes it's a case of being drunk on power, sometimes new personnel are brought in to weed out the employees who are earning a little more than a newbie would. Basically it is the 'warm body' method of hiring and firing. The fact that you were really good at your job and weren't even working that assignment had nothing to do with it. You were targeted and something would've been manufactured to get you out the door.

It happened that way at a job I had once; 'fortunately' I was out on medical leave and missed the entire three month blood-letting. By the time I got back on the job, the 'trouble-shooter' was long gone, as well as more than a dozen really exemplary nurses.