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

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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!!!

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.

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Specializes in ICU, telemetry, LTAC.
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.

WHAT on EARTH is wrong with breaking a pill to obtain the correct dose! Did they want you to overdose the patient? My facility has a pill cutter on every med cart and we are expected to give the correct dose, if that means cut the pill then by god, you cut the pill.

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Specializes in ICU, telemetry, LTAC.

About opening meds in front of a patient... it is a wonderful thing to do because when you tell them what you are giving them, as you open it, all sorts of info becomes available. Yesterday morning I arrived in my patient's room, with my MAR notebook, a cup on top, and two baby aspirin already in the cup (floor stock, those come out of a bottle).

Plop! This is your (whatever blood pressure med that was...), plop, this is your colace, plop! this is (some orange round thing that looks like a baby aspirin except it's darker), plop! this is your klonopin... at that point I have to stop because my patient says, "oh, I just took my klonopin." (I don't this morning remember the names of all the stuff my patient took yesterday, sorry. That's why we have MAR's.)

I just stood there. I did see her putting on makeup, and there is a prescription med bottle in her little tray thing... has she been taking klonopin from her purse willynilly when she wants to? eek! "Maam, just now?" "Oh yes, the night nurse gave it to me and I didn't want it then so I stashed it and took it just now."

OOOkay. So I explain that I'm not allowed to do that, either tell me whether you are going to take it right now, or not. And she says no, thanks, I don't need it. Hmm.

So at least half her meds are unopened. Set those aside on my notebook and back to the cup. Gotta find that klonopin! Baby aspirin and BP med are ok, I know what they are, this leaves me 2 pills, one of which is klonopin. I give the things I recognize (and have not opened) and the patient assures me the pink one with R33 on it is klonopin. Pharmacy confirms this for me, so I get to send them back my opened pill. I do NOT for the life of me understand why benzo's aren't in the narc drawer, but they aren't, so the procedure for this is much simpler.

Now if I had gone in that room with a cup full of pills, instead of opening them in front of her, I'd have given her a double whammy of klonopin because she wouldn't have told me what happened.

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Specializes in med/surg, telemetry, IV therapy, mgmt.
the medication error rate in hospitals is about 26%. . .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.

Medicare is very seriously behind the movement to track med errors. The reason is because they have the data to show that medication errors and adverse reactions to medications increase hospital stays and therefore increase the amount of money they have to pay out. This data is coming from DRG and MDS reporting. 100,000 people die annually from drug reactions (this is from the Institute of Medicine) and it is the 4th leading cause of death in the country. This same source states 350,000 nursing home patients die yearly from adverse drug reactions, some due to medication error. This is a big, big issue right now. They also know that the more medications a patient takes, the chances of a medication error occuring increases exponentially. The jury is still out on this whole issue of drug interactions, drug errors and drug reactions. It is not going to go away. The reason is because of computer tracking which is how this stuff came into the light in the first place. The statistics are telling the story and Medicare will lead the stampede to figure out how to reduce the cost overruns these incidences cause.

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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."

She wrote oxyCODONE , as in percocet, not oxyCONTIN. Anyway, it does seem weird that 5 of them would be in a cup, and while all the hysteria seems harsh, they probably wouldnt have done any of it if she hadnt given out 5 narcotics. They probably suspect her of diverting, or the other nurse set her up, more likely, since she is the one suspended and escorted out of the building. Either way, someone was taking the fall for 5 narcs missing at a shot, we all know this. And, rightfully, or not, it was this nurse. And besides, she DID give the meds. Thats like rule ONE they drill into you in nsg school. Never give pre poured meds from another person.... and ... percocets are BIG pills.... didnt 5 of them seem a bit weird????? (assuming you were someone who would give a cup full of 5 meds to someone that you didnt pour, AND you didnt recognize the difference between them and phenobarb???)

I have many questions ........

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if the pt is doing ok and nothing wrong happend to the pt than why would they suspeneded you?

Because we are talking narcotics here, a whole different scenario than an ordinary "med error" . The facility has state and fed govt to answer to.

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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.

Are you a nurse?

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.... and ... percocets are BIG pills.... didnt 5 of them seem a bit weird????? (assuming you were someone who would give a cup full of 5 meds to someone that you didnt pour, AND you didnt recognize the difference between them and phenobarb???)

I have many questions ........

Yes, that strikes me as very odd. It seems like there is a lot of the puzzle that is missing.

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UM just to clarify, Percocet is a combination of oxycodone and acetaminophen. The oxycodone where I work is supplied in small round 5mg tablets.

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After spending the last ~2hours reading through this thread I have just a couple of comments.

I agree w/ the OP who said that you were courageous to share your story with us. Even though I have been nursing for over 12 years now, reading your story has once again put the fear of the BON in me. Something so seemingly innocuous turns into something so hideous. I am sure that most people reading this have had their eyes opened...whether they be new grads or well-seasoned nurses.

Take the time needed to decide what is best for you. Do what you have to do to make yourself right. I do hope that you don't give up on nursing. We need as many of you as we can get!! My best to you. :icon_hug:

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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!

I was thinking the very same thing! Maybe because I'm an "old" nurse and I believe I have seen and heard just about every trick out there. I was curious about a few things:

Did you look at the meds in the cup?

Did they all look the same?

Do you have any gut feelings that "maybe" this was a set up?

Regardless, let this be a lesson....NEVER give anything that you didn't pour or draw up yourself. My license is priceless, in addition to the above, I don't waste with people that I don't witness the waste. Believe me when I tell you, that you can't always tell (by appearances) who has a narcotic problem. There are many nurses out there who hide it very well. They can be nice, smart, funny and even "great" nurses, but they will get their narcotics anyway possible. Even letting you take the rap!

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