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

[iluvivt, BSN, RN]

I agree, they were out to get you and wanted to create a paper trail.If they could not find something they were going to manufacture something.Of course it is not fair but it is the way it is on many places. I am glad you produced the evidence to prove them wrong but it would not have changed things.You are expecting people in power not to abuse it because it is fair and just to conduct ones self in that manner but so many will not.You can ride it out and hope karma meets up with the abuser of power or you can press the delete key and get out of there. No use at all to be.concerned about what she thought anymore. Leave with your head high knowing they lost a good and decent nurse.