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

Daytonite, BSN, RN · Aug 29, 2005

right attitude? or did you mean right to refuse? :roll

no, you read correctly. the right attitude. it refers to a nurse keeping a positive attitude toward medication therapy that contributes to a positive response on the part of the patient. it has been talked about among those who administer research medications and a patient expresses negativity about the idea that he might be one of the ones receiving the placebo.

markreyes_23 · Aug 29, 2005

HI Julie! thanks for sharing your shocking experience in terms of medication error. This is a remarkable lesson to me since am only 4th year nursing student here in the Philippines. I have never been into a medication error but thanks again. I can only give you is this; just move on anyway the patient is out of danger and I think he would not sue you at all because nothing happend to him. Just always focus on what you are doing. The next time you encounter such situation Im sure you are smart enough to handle such.

:) Goodluch and God bless!

mandrews · Aug 29, 2005

I got my license suspended but I will have it back in two weeks and I will be back to work. 3 years probation for narcotic discrepencies. WOW! But I lived to tell about it even when I thought I wouldnt. I was physically sick, depressed, just ready to give up. Dont. Things will get better! I will be thinking of you. :icon_hug:
Lisa

Lisa,

Glad you can see the light at the end of the tunnell. Been thinking about you.

Did you end up using a lawyer?

melissa :)

Daytonite, BSN, RN · Aug 29, 2005

here's a sampling of some of the responses to this thread that really were upsetting to me when i read them. these are very, very wrong attitudes as far as i'm concerned.

i don't inderstand how come they blame you when the rn said yes for the medication and after giving the medicine she realised it was wrong she should be suspended too.

if no harm was done to the patient, i think that the place were you work is going a lot overboard in having any kind of hearing. have you done something to make them not like you? they need to "chill out" a little bit.

did anything happen to the rn who originally got the pills out and then left the floor??? if she was the one who originally got the pills out,then why are you being persecuted?? i realize that you did give the meds, but, you didn't get them out. wow, i am just shocked!

it just seems to me as if this facility and its administration is trying to put their lack of staffing, poor safety practices, and probably lack of following state guide lines on the rn's and your shoulders.

gosh, we are all human...i'd say the only problem u had was that u didnt document your attempts to answer the reason why the narc count was off.....

glad nothing happened.

these two were just the best (and i mean that sarcastically)! i can't believe that licensed nurses would make comments like these:

it sounds like the treatment for trusting another nurse is totally uncalled for.

the only error you made was by doing her a favor.

MacNurse · Aug 29, 2005

Here's a sampling of some of the responses to this thread that really were upsetting to me when I read them. These are very, very wrong attitudes as far as I'm concerned.
It is the culture of blame that is one of the significant systemic reasons why medications/medical errors are under-reported by health care professionals.
Was there an err made by the OP and the RN? Yes. Of course.
Was the error taken care of immediately? Yes, pt was assessed promptly and sent for observation in what sounded like a timely manner.
Did she take responsibility for it? Yes. See above, and the OP has admitted culpability here.
Will she ever give meds she hasn't poured again? Not likely (snowball's chance in .... that she will IMO)
Does it sound like management responded in a supportive way to make the error a learning experience? No.....
I think everyone that is posting in support of the OP is recognizing that management's response to the situation was not appropriate or supportive considering the response by the OP to the error and the patient outcome.
What do you think the odds are of another nurse reporting an error at that facility after seeing the treatment of the OP and the RN? :stone
Just another thought: No one's perfect, we all make mistakes....

Nesher, BSN, RN · Aug 29, 2005

I have several mistakes in my background that I thought I would share as they are certainly worse that the one Mama2-3 described.

The first was when I was several months into a new job/state. It was nights of course I was in charge - I with several months experience total. At the end of report at 11:30 I was called into a patients room. She was in the bathroom, which looked like a blood bomb had gone off. Blood everywhere. I don't know how she did that - the blood was on all 4 walls - waist high. She was covered - the bedroom and bed looked a massacre had taken place. She had had a vag bleed - cervical Ca. At any rate, stat hct, etc etc, endless cleanup, I was to say the least a tad frazzled when I finally had her settled. My next patient called for me and asked for benadryl. She was a sickle cell patient - frequent flyer and the narcs made her itchy. I grabbed the med and gave it to her. This before the days of PYXIS and all the meds were jumbled together in a bin - all their prns etc. As I walking out the door to get something else for her, she sat straight up and started to seize (grand mal) as well as projectile vomit - all the way across the room.

What had I given her? I can tell you there is a difficult to breathe feeling as well as that gnawing knowledge that I must have given her something bad. I actually went back into the med room and dug through the garbage - I was sure I hadn't!

Clearly I had. It turned out I had given her compazine instead of benadryl - the containers were the same size and the print on each of them was in black - thus my mistake - I had in my frenzied state from the other patient and her bleed out had not looked closely. Now granted it should not have been in her bin since she had an allergy to it, but it doesn't excuse my not checking closely. She ended up being fine - the hospital paid for her admission and I was forevermore uncomfortable around her. This wasn't my last med error that year though.

The second biggie I did was with a 19 year old with neurofibromatosis (spelling) which had become cancerous - She had a huge inoperable abd tumor that made her look 9 months preg. This tumor had also wrapped around her ureters and among the many problems she had was enormous pain. She had a forest of IV pumps in her room on both sides of the bed. Several pumps were hooked to the caths keeping her ureters infused with medication - I don't recall the purpose) - she also had antibiotics, IVF, 2 PCA's one with MS one with versed and another pump for her epidural gtt. This was before the days of locked epidural specific pumps. She had come racing back from a procedure and the epidural bag was empty - so I changed it quickly and got her back into bed - an arduous process. Her pain kept increasing all evening.

It wasn't until the next day when I go to work that I was told what I had done...I had hung Vanco instead of whatever it was she had for her epidural - talk about your heart sinking to the floor. It turns out a person can get Vanco into the epidural space, and because the gtt was at a slow rate she didn't exceed the amount allowed. I was her primary nurse so I continued to care for her until her death. I felt pretty bad about contributing to her pain though...

Those two mistakes occurred when I was a newbie and I recognize their value in teaching me to slow down - take the time to look at what you are giving and to remember you are a human and to be thankful when your screwups don't permanently harm someone.

In your case however, it seems like a huge case of overkill and overreaction!!!

Mama2-3 · Aug 29, 2005

I have several mistakes in my background that I thought I would share as they are certainly worse that the one Mama2-3 described.
The first was when I was several months into a new job/state. It was nights of course I was in charge - I with several months experience total. At the end of report at 11:30 I was called into a patients room. She was in the bathroom, which looked like a blood bomb had gone off. Blood everywhere. I don't know how she did that - the blood was on all 4 walls - waist high. She was covered - the bedroom and bed looked a massacre had taken place. She had had a vag bleed - cervical Ca. At any rate, stat hct, etc etc, endless cleanup, I was to say the least a tad frazzled when I finally had her settled. My next patient called for me and asked for benadryl. She was a sickle cell patient - frequent flyer and the narcs made her itchy. I grabbed the med and gave it to her. This before the days of PYXIS and all the meds were jumbled together in a bin - all their prns etc. As I walking out the door to get something else for her, she sat straight up and started to seize (grand mal) as well as projectile vomit - all the way across the room.
What had I given her? I can tell you there is a difficult to breathe feeling as well as that gnawing knowledge that I must have given her something bad. I actually went back into the med room and dug through the garbage - I was sure I hadn't!
Clearly I had. It turned out I had given her compazine instead of benadryl - the containers were the same size and the print on each of them was in black - thus my mistake - I had in my frenzied state from the other patient and her bleed out had not looked closely. Now granted it should not have been in her bin since she had an allergy to it, but it doesn't excuse my not checking closely. She ended up being fine - the hospital paid for her admission and I was forevermore uncomfortable around her. This wasn't my last med error that year though.
The second biggie I did was with a 19 year old with neurofibromatosis (spelling) which had become cancerous - She had a huge inoperable abd tumor that made her look 9 months preg. This tumor had also wrapped around her ureters and among the many problems she had was enormous pain. She had a forest of IV pumps in her room on both sides of the bed. Several pumps were hooked to the caths keeping her ureters infused with medication - I don't recall the purpose) - she also had antibiotics, IVF, 2 PCA's one with MS one with versed and another pump for her epidural gtt. This was before the days of locked epidural specific pumps. She had come racing back from a procedure and the epidural bag was empty - so I changed it quickly and got her back into bed - an arduous process. Her pain kept increasing all evening.
It wasn't until the next day when I go to work that I was told what I had done...I had hung Vanco instead of whatever it was she had for her epidural - talk about your heart sinking to the floor. It turns out a person can get Vanco into the epidural space, and because the gtt was at a slow rate she didn't exceed the amount allowed. I was her primary nurse so I continued to care for her until her death. I felt pretty bad about contributing to her pain though...
Those two mistakes occurred when I was a newbie and I recognize their value in teaching me to slow down - take the time to look at what you are giving and to remember you are a human and to be thankful when your screwups don't permanently harm someone.
In your case however, it seems like a huge case of overkill and overreaction!!!

Wanted to thankyou so much for your support and in sharing your story with me.When things like this happen you tend to feel like you are the only one on the planet that has ever gone thru this.You and the other nurses have made me feel so much better.I am still suspended,I have not heard anything yet,the RN that was involved in this called me this morning very upset.She had been on the phone with administration and they said they were going to make a decision today and let her know at least.She had obtained a lawyer out of her own pocket expenses,I told her she needs to speak to the union representative and to try and be patient.They should call tomorrow.She is alone without any family,all her family is in Korea.I feel sick for her,I have been praying for strength as we go thru this trial.NO matter what we told the truth.Many of you have said for us to move one,I totally agree but we cannot until they make a decision.Thanks so much for all your support!!

MQ Edna · Aug 30, 2005

VERY FISHY! How do you know the RN didn't actually take the pain pills and the correct meds were actually in the cup? If 5 pills were missing from the narc count, they could have easily been in per pocket, with the correct pills being in the cup and you never knowing it. Did anyone check the supply of the other medication? If security was meeting you at the door, it sounds like this RN was pushing all the blame off on you and blowing the situation out of proportion. It sounds like she had a supervisory role....which means she could have imput into what happens to you. She could have been the one putting you on suspension!

oldnurse newnurse · Aug 30, 2005

Just a little reminder NEVE EVER NEVER NEVER NEVER give meds poured by anoother nurse never sign a telephone order taken by another nurse because you have to cover your ass (license). I'm a LPN also last six years and jobs do not usually stand behind thier employees like that. I've seen employees with twenty year history be fired, and like you said, literally escorted out of the facillity for a mistake much like yours. The nurse that poured the meds nothing happened to her? I feel she made a med error just as much as you, but they were harsh. Sorry your a nurse keep your head up.

oldnurse newnurse · Aug 30, 2005

I have realized thru all this,that I am not infallible.I guess in the back of my mind I thought I would never make a mistake.God knocked the chip off my shoulder and sent me back down to earth.NOw I will have to pay for my mistakes.I am so glad you have decided to go back.You are a bigger person that I could ever be.I am just waiting for an answer from my place of employment,then I will put in my 2 weeks notice.Nrsg is stressful enough,but if you don't have the support of your administration your sunk.Thanks so much.Remember, when God closes one door,he opens another.

well, I work in Illinois as a nurse and I know for a fact that a lot of companies are like that here, so you deal with it and go on about your business. I am very careful about everything I do and I pass no one else's poured meds. But it seems to me like nursing eat their young and the field is not as supportive as it should be. I graduate in Dec. BS in nursing and hope I can become a manager somewhere after a while and offer some needed and wanted support to our nurses in the world. maybe I'll start a new trend.

quezen · Aug 30, 2005

Good Grief! That was a little punitive. Was this your first med error? What was the consequence to the pt as a result of the med error?

When I worked for United States Indian Health Service I was charged with three med errors. (1) Breaking a pill in half to obtain the correct dose (2) Unhooking a patient from his (NS) IV at the end of the shift so he could go to the bathroom and not hooking him back up before I gave report, and (3) Not moving a 6 foot oxygen cylinder with a patient who wanted to change beds (the patient was fine and discharged the next morning).

These cost me my job after 11 years with the federal governmnet.

Julie, you have my sympathy. I know the feeling and the stigma. If no one supports you I want you to know that the hurt will fade and if you stay in nursing you may make mistakes again but you will become sly as a fox so that you can survive. Rule #1, if they are chronically understaffed, don't enable them by working there.

slinkeecat · Aug 30, 2005

Well, first of all I am sorry that you have made this error. Your Facility is probably gearing up since this is a SENTINEL EVENT and there will be reprecussions all the way around.

MED Errors are 1 of the top reasons of patient deaths/ injuries.... So much so that there was a big report a few years back.... IT IS A BIG DEAL. Just because the Patient did not die, does not take away from the fact that procedure was not followed and that being said, while I commend you for taking responsibility and accountability for the lax in judgement you demonstrated, the fact remains that you did not follow the cardinal rules.

Now we can all debate about well, We're short staffed, busy, harried, and we need to take short cuts... but these little short cuts, kill people and cost money and ruin careers.

The RN is equally accountable.

My Advice:

Utilize your Union attorney

Get personal Liability Insurance

In Good faith, find a CEU course on the legalities of Nursing and Medication Rights in case it is reported to the board you can be proactive in demonstrating to them you are taking to corrective steps to prevent. and educate yourself.

Good luck to yourself.

One more thing.... what is the family's take on things.... Are they threatening lawsuit???

Just out of curiosity.... what state this happen in????