Med error,I'm suspended,I need advice,please!

Bill Levinson · Oct 8, 2005

Here's a little rundown of what happen.40 bed unit,we were short a nurse so the RN that was covering the house had to take one cart.9pm at nite she was called to another floor for an incident that had taken place.I was at the station trying to catch up on a pile of charting and numerous other things.ONe of her pts. foleys came out and she asked me to look for one,I did that and when I came back she had poured pills for a pt but couldn't give them because he was in the shower.She left them on top of the cart and asked me to give a pain pill to another one of her pts.She left for the other floor,I went to give the pt the narcotic and notice that the count was 5 off.I didn't give him anything until I could find out why the count was off.The gentlemen then finished his shower and was asking for his pills that were prepoured by the RN.I called the RN and asked if she wanted me to give them to him,she said yes and I did(BIG MISTAKE)So happens when she came back and I told her about the narc not being right,she said,Oh my God I put five Oxycodone instead of 5 phenobarbs in the cup.I immediately sprang into action,Assessed the pt.called the DR.CAlled 9ll.Looked for narcan in the crash cart.The pt at this point was fine.He left the building in 10 minutes and was admitted for observation.He returned the next day with no harm done.I was treated like an absolute criminal,I was not allowed to enter the front doors without being escorted and was told by the security(very loudly,not to cross the line.I am sick.

From what I can see here, the fault is not really yours or the other nurse's but the hospital's. The procedure that allows medications to be transferred from labeled containers into unlabeled cups is, as I see it, a catastrophe waiting to happen.

I am incidentally not a health care professional but an engineer and a quality management professional. My responsibilities once included industrial safety and I know that you never put ANYTHING like a chemical into an unlabeled container. The same principle probably applies to medications.

The other nurse said, "Oh my God I put five Oxycodone instead of 5 phenobarbs in the cup." Doesn't the pharmacy fill the prescriptions for the individual patients? If so, (just off the top of my head) the pharmacist ought to put the pills into a SEALED container with the name of the patient, the identity of the contents, and the physician's instructions. The container is not to be opened until it is actually given to the patient (who, if able to do so, should be invited to read the label).

In summary, what happened is at least as much management's fault as it is yours if not more.

--Bill

pattyzaccy · Oct 8, 2005

HI,
I am new to this site and I would like to say hello to all the nurses out there!!My name is Julie and I am an LPN.I made a med error two nights ago and have been suspended without pay till further notice.I have a hearing tomorrow with administration and my union representative.Any advice would be greatly appreciated.Thanks so much!!!

The facility I work at for 23 years sometimes go on a spree warnings, suspensions, for actually missing to sign off initials in the box which is about 300 boxes a shift!! Same supervisors when forced to take a unit make same errors only 10 times worse!! Definitely punishment should be based on consequences to patient or how really big error is our big shot supervisors have hung wrong IV medications and for sure no action taken against them!! Just cover ups...seen this happen few times in my 23 years. :uhoh21:

tridil2000, MSN, RN · Oct 8, 2005

From what I can see here, the fault is not really yours or the other nurse's but the hospital's. The procedure that allows medications to be transferred from labeled containers into unlabeled cups is, as I see it, a catastrophe waiting to happen.
I am incidentally not a health care professional but an engineer and a quality management professional. My responsibilities once included industrial safety and I know that you never put ANYTHING like a chemical into an unlabeled container. The same principle probably applies to medications.
The other nurse said, "Oh my God I put five Oxycodone instead of 5 phenobarbs in the cup." Doesn't the pharmacy fill the prescriptions for the individual patients? If so, (just off the top of my head) the pharmacist ought to put the pills into a SEALED container with the name of the patient, the identity of the contents, and the physician's instructions. The container is not to be opened until it is actually given to the patient (who, if able to do so, should be invited to read the label).
In summary, what happened is at least as much management's fault as it is yours if not more.
--Bill

the pharmacists do not dispense meds to the pt. the nurses do. so no matter what they send, even if it is incorrect, we are still primarily responsible, as we should be.

most units have their own stock of narcotics that are double locked and a nurse must hold the key. the narcotics must be taken from the locked box by a nurse, either an lpn or rn, signed for, and then given directly to the pt. three or four times a day, narcotic count must be done by 2 nurses.

the nurse who pulled 5 percocet out had NO business doing so, bc the most you can take at once is 2.

the whole story sounds fishy.

Nurseinthemaking · Oct 9, 2005

Here's a little rundown of what happen.40 bed unit,we were short a nurse so the RN that was covering the house had to take one cart.9pm at nite she was called to another floor for an incident that had taken place.I was at the station trying to catch up on a pile of charting and numerous other things.ONe of her pts. foleys came out and she asked me to look for one,I did that and when I came back she had poured pills for a pt but couldn't give them because he was in the shower.She left them on top of the cart and asked me to give a pain pill to another one of her pts.She left for the other floor,I went to give the pt the narcotic and notice that the count was 5 off.I didn't give him anything until I could find out why the count was off.The gentlemen then finished his shower and was asking for his pills that were prepoured by the RN.I called the RN and asked if she wanted me to give them to him,she said yes and I did(BIG MISTAKE)So happens when she came back and I told her about the narc not being right,she said,Oh my God I put five Oxycodone instead of 5 phenobarbs in the cup.I immediately sprang into action,Assessed the pt.called the DR.CAlled 9ll.Looked for narcan in the crash cart.The pt at this point was fine.He left the building in 10 minutes and was admitted for observation.He returned the next day with no harm done.I was treated like an absolute criminal,I was not allowed to enter the front doors without being escorted and was told by the security(very loudly,not to cross the line.I am sick.

Whoa, that is scarey. I am with someone who said earlier, you don't want to work there anyhow. Why would you give a med someone else had pulled? As nurses we know better then that. Never ever ever do that.

BUt, this seems harsh, the punishment does not fit the crime at all.

feebs · Oct 10, 2005

Maybe it's my suspicious nature, but 4 extra Oxycontin not causing an adverse reaction seems suspicious. This is why you don't give anything you don't pour, because you don't know what it is, but along with using this as a learning experience for you, I'd be watching the RN for diversion. Along with pounding into me "don't give anything you don't pour" is the "don't leave unattended anything you did pour, especially narcotics."

Funny, that is the very first thing that I thought of. Why wasn't there an adverse effect for that much narcotic. I had the same thought, that the RN could have diverted some of the drug. but you would think she would be under suspension or observation. :specs:

feebs · Oct 10, 2005

At my hosptial we utilize the Electronic medication admin system. I really like the idea and am not sure at this point I would ever want to work in a facility that does not have it. Of couse one still has to be extremely vigilant in med admin, do all the checks and do not assume the pharmacy is always correct. There is no substitute for taking time and doing things right. Each nurse has his/her own cart with the meds in an envelope in a file type drawer. The cart has a laptop. I always have instant access to the pt info. Of course to double check orders I need the chart. Everything is unit dose, the pt is scanned, the med is scanned and the nurse will be alerted if it is the wrong med, wrong dose, wrong time etc. Its all in "real time" done live. Narcs are kept it the pixis, but they are still scanned before being given to pt. It has it's drawbacks in some areas, such as dragging the cart to every pt, low battery power, broken scanners,etc. We also do our charting by computer. Over all, I think it is a great saftey feature. It has decreased med errors by 80% since implementation. Let me hear from you all if you use this system.

we use the emar system at my hospital in north florida( Ocala.) I have been using emar since it was introduced at another facillity in Gainseville, north florida. I love it. Even tho it is a fast paced floor, the scanning does bring up any discrepancies before you even open the package, and especially before you give it to the patient. I have been an RN for about 6 years, worked at a lot of hospitals, in varied conditions.. Med errors do happen, especially in the crowded Florida hospitals. short staffing, high acuity, constantly being under pressure to get it all done. The electronic mar does slow things down a bit, but overall is much safer. :cool:

Mama2-3 · Oct 10, 2005

QUOTE=feebs]Funny, that is the very first thing that I thought of. Why wasn't there an adverse effect for that much narcotic. I had the same thought, that the RN could have diverted some of the drug. but you would think she would be under suspension or observation. :specs:

The pt. should have gotten 150mg. of phenobarbital instead of the oxycodone.He did not have even have an order for oxycodone,it was another pts. She did not look at the label when she was pouring the med nor did she sign it out when she did pour it or she would have caught the error.I caught the error when I went to give the oxycodone to another pt.and realizied there were five missing.What a screwed up mess,yes,I am at fault for giving another med a nurse had poured,I admitted to it,didn't try to cover anything up.I was suspended for 3 days,the RN for 5.The RN is filing a grievance for her 5 day suspension saying it was too harsh.I am not grieving anything,I have let it go and am going on with my life.Have a great day!:)

SmilingBluEyes · Oct 10, 2005

And, on that note, I will close the thread. I wish the OP the best in her endeavors after this incident.