Med error and disciplinary action

[Trolleydoll]

Hi all,

I just began a new nursing job just short of three months ago. I recently made a med error where I pulled the med out of the Pyxis for the wrong patient. The pt's name were the same but middle initial was different. The correct med was given to the correct patient it was just pulled from Pyxis under the wrong name (duplicate pt names just different middle initial). No harm to pt, md notified and incident report filed.

I was was given an escalated disciplinary action for this, since I am on probation at this new employer and that disciplinary action will follow me for 1 year giving my employer the ability to terminate my employment for any adverse action within the next year. This includes if I'm late or call out sick.

I informed my director of the error immediately and mentioned how we don't have a similar name warning in the Pyxis. I have been an RN for 14 years and take responsibility for my actions, but feel this protocol is unjust. I asked to contest it with HR.

I feel this policy of disciplinary action is wrong and voiced this to my director. It discourages nurses from trying to fix a flawed system and encourages non reporting of errors.

Any advise on how to handle this with HR? Any feed back is welcome!

[Lev, MSN, RN, NP]

That sounds like a very tough disciplinary action for pulling a med under the wrong patient's name. It was a simple easy mistake that didn't lead to any harm. I personally would not have filed an incident report and I see no reason for notifying the MD. I would have taken the med out under the right patient's name and then "returned" the med for the "wrong" patient.

[SionainnRN]

Holy crap so you can get fired for calling out sick now? That is a huge over reaction in their part! I would fight it! I'm so sorry you're dealing with it.

[pghnurse07]

That's crazy. And you're right, that does prevent people from reporting errors. At most, you should have done some re-education on the five rights with your educator.

[kaylee.]

This is not entirely your fault! They should have a name alert!

Its the same concept as meds with sound alike names being placed in completely different areas of the pyxis--to make grabbing the wrong one nearly impossible.

And the fact that they are placing disciplinary action on you, for something rather benign that could be easily corrected. Seems pretty severe for something that clearly has a systems error component.

[Silverdragon102, BSN]

And then companies are concerned when med errors do not get reported. With treatment like this it is no wonder. Med errors should be a way at looking at what went wrong, why did it go wrong and what could be done to prevent or minimize re-occurrence

[CrunchRN, ADN, RN]

Wow. Totally over the top. I am sorry you are being treated this way.

[Karou]

That is just ridiculous. I am sorry you are dealing with this. The reaction that you are getting seems way too harsh to me.

[SierraBravo]

That sounds like a very tough disciplinary action for pulling a med under the wrong patient's name. It was a simple easy mistake that didn't lead to any harm. I personally would not have filed an incident report and I see no reason for notifying the MD. I would have taken the med out under the right patient's name and then "returned" the med for the "wrong" patient.

I agree with this. I'm not clear on why you notified the MD; he/she wasn't even tangentially involved in the situation. I understand filing an incident report. But like someone else said, why not just return the med and then take it out again on the right patient? Seems like a simple fix that could have avoided this whole situation.

[psu_213, BSN, RN]

This isn't even a med error. Might be a billing issue, but it is not a patient care issue. There have been times when a pt. is admitted to the ED, their name is not in the Pyxis yet, an emergency med is needed, it gets "pulled" under another patient...sometimes this is corrected once the person's name is in the Pyxis, other times it's not. No biggie.

Count me with the nurses who would not have written and incident report and would not have notified the doctor. I'm surprised the doctor did not say "what are you talking about?" or "why does this even matter to me?"

[Loo17]

Im guessing that the facility policy states the doctor needs to be notified? I know that the last place I worked that had a paper incident report there was a box that had to be checked that you contacted the MD and then you had to fill out the doctors name and time they were contacted.

I hope that HR assists you in having this write up removed from your file. Good luck!

[No Stars In My Eyes]

And then companies are concerned when med errors do not get reported. With treatment like this it is no wonder. Med errors should be a way at looking at what went wrong, why did it go wrong and what could be done to prevent or minimize re-occurrence

^^^^^THIS!^^^^^

Knee-jerk, punitive, out-of-context over-reactions are what keep people from reporting something. Instead, we hold our breath, hearts in our throats, fearing discovery. Yes, there are degrees of POTENTIALLY serious outcomes in any incident or occurrence, but that your career might get trashed shouldn't have to be the first thing you think when you catch yourself in a mistake.

I worked at a place where 'borrowing' a med from another patient was a huge No-No, no matter WHAT!

One nurse was put on probation because she was 'caught' using someone else's Tylenol for a patient whose pharmacy delivery did not arrive in a timely fashion. I mean, let's get a little perspective here!

Borrowing a Tylenol here is not the 'gateway' to drug diversion!