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!

[KelRN215, BSN, RN]

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.

Same. I would not have filed an incident report in this instance (there was no "incident", the correct med was given to the correct patient) and I most definitely would not have notified the MD. Why would the MD need to be notified? It had zero to do with him/her.

[imintrouble, BSN, RN]

I made a med error last week. Nobody was hurt. Nobody would know but me.

Really minor, but it was an error that should have been reported. So I did. I filled out the appropriate form and turned it in. I knew there wouldn't be any punitive action taken.

If I worked in a place that would assign me points, I never would have reported my mistake. Or at the least, I would have thought long and hard about turning myself in, for an extremely minor mistake that had no impact on patient care.

[Salter444]

I get the feeling there is more to this story that being shared here. The odds are that every nurse will be involved in a medication error - it is the human aspect of the job that makes us prone to making mistakes. An incident report is designed to be a non punitive process and I cannot see how if harm did not reach the patient this becomes a disciplinary issue and not an opportunity to correct a process or provide education.