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

Nurse Ratched, RN · Aug 25, 2005

There are different degrees of medication errors. Those that

(1) didn't reach the pt (but had potential before being caught) and caused no harm,

(2) did reach the pt, but didn't cause harm,

(3) did reach the patient and caused harm, but no major adverse effects, or

(4) did reach the patient and caused major adverse effects.

Pharmacy's primary concern is weeding out systems problems that may lead to errors. ISMP.org is a great source of info - your facility likely subscribes to it.

In this case, a fundamental error of "wrong med" was made. The reason one shouldn't give a med one hasn't gotten out of the package personally is that you can't be sure that it's the right one. This is an important lesson in "the faster I go, the behinder I get." The degree of punishment seems extreme, and certainly doesn't seem like it was meted out in an equitable fashion.

To answer the question posed by another poster as to why an action that did not actually harm the pt is being punished in this manner, I can only say that the powers that be appear to be taking this seriously to avoid future recurrences (that could harm a patient) from a very avoidable error.

I hope this sorts out for you.

grannynurse FNP student · Aug 25, 2005

hi grannynurse,
when i was a nursing student one of the things pounded into my head was the fact that you never give medications that you did pour myself, you will be held accountable if the medication was poured incorrectly. also pounded into me was never ask another nurse to give meds that you poured. two of the many things nursing instructors drilled into me that i will never forget. also if you are providing medication to another nurses patient, check the order before you give it. unfortunately there are the few posters who don't understand why she is being held responsible for this.
i don't think the poster is trying to avoid responsiblity for her actions in this situation. i do think she learned one lesson the hard way. the rn was also wrong in this situation.
i've seen worse nursing errors that have never been handled the way this situation was.
do you think it was appropriate for security to escort her off the premises and suspend her prior to any investigation of this incident?

as you may have guessed, i have been a nurse for a long, long time. one of the first rules, i was taught, never, never, never give a medication you, yourself did not pour. and there is never an acceptable excuse for giving a medication one did not pour. to be honest, i do not understand the problem that some posters are having with her being held responsible. that being said, the employer errored in also not holding the rn responsible, for her medication mistake and for asking another nurse to give something she had poured.

to be equally honest, the both of them should have been suspended until the issue was resolved. not knowing the reason for the security escorting her off, i really can't comment.

grannynurse :balloons:

DusktilDawn · Aug 25, 2005

Hi Grannynurse,

I agreed with what you said in your initial post. Just curious as to what you thought about the actions taken. Thanks for answering.

CrunchRN, ADN, RN · Aug 26, 2005

Seems pretty harsh. An error made, identified, make a plan to prevent it in the future. Escorting someone off the property and suspending them seems extreme. This was not a purposeful act with an intention to harm. I just get disgusted sometimes that nurses are expected to be perfect when that is impossible under the best of circumstances, and with low staffing levels and high acuity, and lack of support how can people NOT expect these things to happen. We all know that horrible, awful sinking feeling in our guts when an error is made, and then you think about it obsessively over and over for weeks because you feel so awful. Do you also need suspension? I don't think so.

Now, repeat offenders, and slackers are a different subject and they deserve that kind of treatment, but that wasn't the case with this nurse.

Whew - guess I had to get that out. Feel free to let me have it! :lol2:

Mama2-3 · Aug 26, 2005

Seems pretty harsh. An error made, identified, make a plan to prevent it in the future. Escorting someone off the property and suspending them seems extreme. This was not a purposeful act with an intention to harm. I just get disgusted sometimes that nurses are expected to be perfect when that is impossible under the best of circumstances, and with low staffing levels and high acuity, and lack of support how can people NOT expect these things to happen. We all know that horrible, awful sinking feeling in our guts when an error is made, and then you think about it obsessively over and over for weeks because you feel so awful. Do you also need suspension? I don't think so.
Now, repeat offenders, and slackers are a different subject and they deserve that kind of treatment, but that wasn't the case with this nurse.
Whew - guess I had to get that out. Feel free to let me have it!

JUst wanted to thank you for your support and all the wonderful nurses for theirs as I am dealing with this med error thing.I absolutely did the wrong thing in dispensing those meds without pouring them myself.I am still suspended.I had my hearing yesterday and told my part of the story.The patient is fine,bottom line.I have never made a med error before.I will never do this again.When this whole mess is taken care,I will be leaving nrsg.I was treated like a common criminal if front of the families of the pts that I take care of.Did I deserve it,absolutely not.Not only did this security guard defame my character the other day,on the way out of the building,he yells in front of everybody,"Are you guys done with her!!Real nice.Anyway,I need to move on after this is all over.I don't know which has destroyed me more,my stupid med error or being disgraced in front of everybody.Thanks so much for all your support,I really needed it.I know when God closes one door he opens another one.

wooh, BSN, RN · Aug 26, 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."

DusktilDawn · Aug 26, 2005

It may be that facilities policy to suspend in a situation like this. The patient had to be taken from the facility and admitted for observation, perhaps in a situation that results in hospitalization, suspension until the incident is investigated is part of their policy and procedure.

Every place has their own policies for dealing with medication error whether we feel they are fair or not. If this incident occurred without having to transfer the patient outside the facility, the situation may have been dealt with differently.

The fact that the gentleman had to be transferred out to another facility for observation may make the incident more serious in the eyes of management. You can't exactly deal with it internally. Escortion off the premises wasn't necesssary IMO, they could have talked to her or called her at home.

Believe me I think all factors involved in a medication error needs to be look at to prevent similiar errors in the future. I don't think escorting any one off the premises like a criminal is at all necessary.

gr8rnpjt, RN · Aug 26, 2005

she said,Oh my God I put five Oxycodone instead of 5 phenobarbs in the cup.

What was done to her? sounds like her med error, not yours. Hope they are giving her the same or worse treatment. The meds already poured? I don't see what was your fault.

DusktilDawn · Aug 26, 2005

JUst wanted to thank you for your support and all the wonderful nurses for theirs as I am dealing with this med error thing.I absolutely did the wrong thing in dispensing those meds without pouring them myself.I am still suspended.I had my hearing yesterday and told my part of the story.The patient is fine,bottom line.I have never made a med error before.I will never do this again.When this whole mess is taken care,I will be leaving nrsg.I was treated like a common criminal if front of the families of the pts that I take care of.Did I deserve it,absolutely not.Not only did this security guard defame my character the other day,on the way out of the building,he yells in front of everybody,"Are you guys done with her!!Real nice.Anyway,I need to move on after this is all over.I don't know which has destroyed me more,my stupid med error or being disgraced in front of everybody.Thanks so much for all your support,I really needed it.I know when God closes one door he opens another one.

Absolutely no reason for you to be escorted off the premises in this manner. What you describe sounds horrible. Please don't make the decision to leave nursing when your obviously this upset.

Mama2-3 · Aug 26, 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 narThere was a pharmacist in the building that night,the pt.should have recieved 150mg of phenobarbital instead of the 25mg of oxycodone.He had a high tolerance level because he recieves the phenobarbital.He was admitted for observation with no ill side effects and sent home the next day.I

Judee Smudee, ADN, RN · Aug 26, 2005

One of our nurses accidently thought that the levophed was an antibiotic (so many IVs were running) and ran it at 200cc/hr. Pt went into HTN crisis, BP >200, HR >170. It was ugly. Pt was a full code, AVR post op day 15 and weighed >400lb, still vented, all lines in, etc...

This same mistake is happening over and over again. Levofloxacin or Levaquin is being mistake for Levophed or visa versa and people are being killed and injured. It is time for the FDA to take action. This is a SYSTEM problem. In my opinion the company that makes Levaquin should not have been permitted to use that name in first place. There is long history of similar drug names causing problems, they know darn well it will happen. For instance Prilosec was Losec when it first came out. So many people got lasix that the FDA forced manufacture to add Pri to name and presto problem solved.

tridil2000, MSN, RN · Aug 26, 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 narThere was a pharmacist in the building that night,the pt.should have recieved 150mg of phenobarbital instead of the 25mg of oxycodone.He had a high tolerance level because he recieves the phenobarbital.He was admitted for observation with no ill side effects and sent home the next day.I
i think this is being handled the way it is because a narc is involved.