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

Monica RN,BSN · Sep 3, 2005

First of all , it would seem to me that having five pills in a cup that look the same would be a red flag, that is NOT usual.. Second, the nurse who put 5 narcotics in a cup had to know they were all there.. she had to sign them out.. I would hope administration is reviewing the narcotic sign out sheet carefully,. I has a nurse sign out 4 vicodin every 2 hours as if given. (ie: 2pm, 4pm, 6pm, 8pm,) and they were not given, because the resident was in hospital.
Had to drug test and suspend immediately.. was a big mess to deal with all that. In my facility BOTH nurses would have been suspended for investigation, terminated after investigation done, and reported to BON in most cases. Giving someone else prepoured meds should never happen, and to have 5 in a cup.. I suspect that the nurse pouring was trying to divert them and got side tracked.. many lessons to be learned here.
Both had a part in being wrong, and suspension is in order from my
perspective.. (yes, I am in management)
Even though no harm was done, it had th epotential to cause serious harm and/or death depending on the individual who recieved them. POTENTIAL is the key word here.. Suppose it was a frail little old 70 lb lady, 5 narcotics coul dhave easily kille dher... many scenerios in which this error could have resulted in death.. Lucky it did not... The bigger question is 1) why there were 5 pills in the cup?
2) why you gave someone elses prepoured meds..especially when all 5 looked alike ?
Sorry you are in this predicament.. good luck.. I think the lesson has been learned.

I did not read all the posts before my reply... i saw that you indicated phenabarb and oxy look the same... so I can almost see what happened here...

Just the same both are accountable.. Glad it turned out ok for you though.

Misty1 · Sep 3, 2005

First of all , it would seem to me that having five pills in a cup that look the same would be a red flag, that is NOT usual.. Second, the nurse who put 5 narcotics in a cup had to know they were all there.. she had to sign them out.. I would hope administration is reviewing the narcotic sign out sheet carefully,. I has a nurse sign out 4 vicodin every 2 hours as if given. (ie: 2pm, 4pm, 6pm, 8pm,) and they were not given, because the resident was in hospital.
Had to drug test and suspend immediately.. was a big mess to deal with all that. In my facility BOTH nurses would have been suspended for investigation, terminated after investigation done, and reported to BON in most cases. Giving someone else prepoured meds should never happen, and to have 5 in a cup.. I suspect that the nurse pouring was trying to divert them and got side tracked.. many lessons to be learned here.
Both had a part in being wrong, and suspension is in order from my perspective.. (yes, I am in management)
Even though no harm was done, it had th epotential to cause serious harm and/or death depending on the individual who recieved them. POTENTIAL is the key word here.. Suppose it was a frail little old 70 lb lady, 5 narcotics coul dhave easily kille dher... many scenerios in which this error could have resulted in death.. Lucky it did not... The bigger question is 1) why there were 5 pills in the cup?
2) why you gave someone elses prepoured meds..especially when all 5 looked alike ?
Sorry you are in this predicament.. good luck.. I think the lesson has been learned.

First of all Monica I'd like to say I don't envy your job in management. Its a tough job and I certainly wouldn't want it.

With that said.....management should also take some responsibility for what happened. Management put the nurses in a bad position being so short. Management IMO is part of the blame.

casper1 · Sep 3, 2005

:uhoh21:
Well administration has made their decision about my med errror.Basically they called me and apologized for putting me thru the stress.Asked if I was okay and asked me to come back to work,I will be with another nurse for one day so she can see how I do my med pass.I asked if I was going to be on the same floor and they said yes,but if I wanted to switch to another floor they would accomodate anyway they could.Just the thought of going back is giving me palpatations.I said that I needed a couple days to think about what I am doing,this has me really shaken up.The RN involved has taken a sick leave,she went to her personal physician and he gave her a leave because of her abnormal heart beat.He also gave her some Ativan to help calm her nerves.I need give them my 2 weeks,this was way too much for me to handle.Thank you so much for all your prayers,telling the truth is the only way to go.

I'm so happy to hear things are looking up. That facility will be very lucky to get you back if thats what you decide.

I think if every experienced nurse would think back to how scary and intimidating being a new grad was for all of us we could do alot to improve the nursing climate in our facilities. None of us likes working short staffed. Lets not chase our new nurses out of the profession. They became nurses because they genuinely care about people. Shouldn't we provide then with support and care. Then we can stand back a year from now and be proud of the wonderful nurses we have helped.

ladylynx · Sep 4, 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.

I must say after just going through a mock Joint Commission survey while passing medications (passing), I feel that my experience of working for various agencies over the past 15 years has allowed me to see things like this incident and far worse. Whether a new nurse or and old nurse, mistakes are made. I still get the evil eye when I: (1) refuse to take a syringre, filled by someone else, and inject a patient, (2) check the Pyxis info on when the med was taken out vs. the MAR, (3) remove meds from the Pyxis and immediately going to the patient and then coming back to remove meds for the next patient, (4) check the Ativan vials to make sure the top has not been previously removed, (5) check for the viscosity of the Ativan, (6) will not change an IV bag for someone without varifying the MAR and asking the nurse, (7) take the written MAR in the room with me, (8) open the meds in front of the patient, (9) make sure the patient knows why they are getting such meds...I could go on and on. Take time and observe around you, these practices are ignored at an alarming rate. You would be surprised how your co-workers are completing their tasks faster than you.

Lastly, to your incident, suspension...of course not! But there should be an inservice regarding policies and statistics reviewed on adverse effects on patients for such actions without naming the persons at that hospital involved. I have also learned a lesson a few times...when the floor is short staffed, don't cut corners for yourself or anyone else. Let the companies justify why meds were late, patients fell, and others just unhappy with the lack of staff. Remember they don't put up a street light at a crossroad until so many accidents happen.

Take care. Peace and love...nothing less! The Lady

waltrip15 · Sep 4, 2005

I wonder If It Hadn't Been A Narcotic would The Incident Report Have Been Enough.

LauraF, RN, ASN, CNA, LPN, RN · Sep 4, 2005

MaMa2-3

Please please please, take this as a learning experience. Don't ever give meds for someone unles you have punched them out. Unless you can verify what you are giving to what patient. I know that the man wanted his pain medication, but no one has died from being in pain for 10 minutes while waiting for the nurse to finish whatever she was doing. People have died by being rushed and getting the wrong medications. I wish you the best of luck in the future, but remember Cover YOUR orifice. You will be the one in court defending your actions.

lisa bear rn · Sep 5, 2005

Thank you so much for your support,it helps to know that other nurses have been thru this,I haven't heard anything yet from my place of employment.The RN that was involved in this incident called me yesterday,the union stewart had called her and said that they were going to report it to the BON.That's where this is headed.It doesn't matter if she poured the medicine,I am just as guilty giving it.I might as well have poured it myself and gave it to him.When you were suspended did you continue to work at the same place?So glad things are working out for you.Again,I appreciate your support so much,it means the world to me.

It depends, if your license is suspended you cannot work as a rn, you must resign. That sucks. That is what happened to me. Now that I am getting my license back, I have to find a new job that will take me with all my restrictions on my license for 3 years. I will be thinking of you, this is a hard situation, but it is able to overcome it!! LISA

SE_BSN_RN, BSN · Sep 5, 2005

You don't want to work there anyway. Get this situation taken care of, and then move on. These people will not be supportive-especially if you have another med error in the near future.

I agree. And this is why you should NEVER give meds that were not prepared by YOU. And they were left out on the medcart where someone could have done who knows what. I hope you get this solved. Chalk it up to a HUGE lesson learned!

lisa bear rn · Sep 11, 2005

Thank you so much for your support,it helps to know that other nurses have been thru this,I haven't heard anything yet from my place of employment.The RN that was involved in this incident called me yesterday,the union stewart had called her and said that they were going to report it to the BON.That's where this is headed.It doesn't matter if she poured the medicine,I am just as guilty giving it.I might as well have poured it myself and gave it to him.When you were suspended did you continue to work at the same place?So glad things are working out for you.Again,I appreciate your support so much,it means the world to me.

No, I am not working right now. Since my license was suspended for a month, I could not work as a nurse and the facility that turned me in fired me, no big deal, I am sure I will be able to get another job. If the BON does contact you, just be straight forward and honest, you might want to write the incidence down so you will remember little details to be prepared. Try to stay cool and not to worry, things will work out. Take this from me, I never ever in the world thought I would be in trouble with narcs and be suspended, but you never know!! Good Luck!

GLORIAmunchkin72 · Sep 15, 2005

Unfortunately, despite the fact the other nurse poured the meds incorrectly it was Mama2-3 who gave the medication to the patient. No matter if another nurse pours the medication, if you give it, you are responsible.
Although personally I feel the that the other nurse has culpability in the situation, legally it may be another matter.
The actions taken after the error was certainly approriate. Assessing the patient, the doctor was notified, pt was admitted for observation. When a medication error does occur (yes, that can happen to the BEST of nurses) all steps must be taken to prevent any further harm to the patient. It sounds that this is exactly what happened.
I can understand the incident being investigated and both you and the RN involved spoken to about it, but suspension at this point seems overboard. The incident should be investigated first before such measures as escorting staff by security off the premises and suspension. Disiplinary action usually takes place after investigation. Have you discussed this aspect with your union representative? What are your policies and procedures involving medication errors? Is suspension until the incident is investigated part of their policies and procedures? I could understand a situation involving patient abuse involving immediate suspension and escortion off the premises.
I do wish you all the best concerning this situation. Please keep us posted.

Escorting you out of the building by security guards is a tad dramatic! I don't even think they did that for the doctor who cut the wrong leg. But since you're just a lowly LPN...

JoBug · Sep 15, 2005

Escorting you out of the building by security guards is a tad dramatic! I don't even think they did that for the doctor who cut the wrong leg. But since you're just a lowly LPN...

I hope you are doing well, as can be expected, I am not going to drill in your head what you already know, just know, as a fellow LPN, my thoughts and prayers are with you, and you ARE a nurse, it is who you are...you will overcome this and be a better person in the end.

JoBug

xrockstheheart · Sep 15, 2005

the medication error rate in hospitals is about 26%, the number are kinda fuzzy because, they are not maintained. however if you extrapolated from the old data you would see it's huge. in fact the number is so high that it is being considered to have this as part of the patients contract when they come in for treatment, you know, informed consent. Their is a instituion that keeps up with this, the Institute for safe Medication Practice. Most errors are system errors, the best way to eliminate med errors is to decrease the number of meds but you know they won't do that because they make money from this, that is why we have to adm meds in an acute care setting that will not go into effect for weeks, months. Take for instance, Calcium for osteoporosis, giving these horse pills to patients hurts them more than it helps, giving Dopamine on the floor has no effect on the patient, and their is no research to prove it, but the docs use it to keep the patients in the hospital longer, because they make more revenue out of this. meds are a funny thing, hell some of them don't even work. Do you homework!!!!

this was my first error as a nurse,I have been a nurse for 5 years.The pt is fine and no harm was done.I feel like I am being persecuted,I feel physically ill over all this.