Med Error

Nurses General Nursing

Published

I haven't posted much before, but I need opinions. I currently work in a long term care facility that is going through a difficult growing phase. The difficulty mostly stems from administration that has no clue about what it's really like to work on the units, but plenty of ideas to "make things better". I'm sure you all know how that goes! Anyway...

The other day I was floated to another unit that is very very hectic. It's a combination of LTC and rehab patients. They have recently began accepting picc lines as well. I was given a short report,had the keys tossed ay me, and was on my own. I began trying to pass meds, field questions from the CNA's, deal with numerous demands from an extremely abusive NP, and basically keep my head above water There was a new admit from the previous day on my assignment. She had no name band on, there were no pictures of any residents in the MAR's(our facilitys protocol!), and no names were on the door to her room. I had been told in report that both residents of this room were alert and oriented. I asked the resident her name and she gave a name I knew to be one of the occupents of the room. I asked her how she took her meds, prepared her pills, and gave them to her. Shortly after that, I discovered that I had actually given her her roomates meds. Thankfully it was nothing major!! I immediately reported the error to the ADON who is running this floor at the moment(No NSG Manager, No Charge Nusrse. They both quit). My question is this. How much of this error was my fault, and how much was the facility's? I do realize that the fault is ultimately mine, but I feel that it was an unsafe situation to begin with. What do you think? What could I/should I have done differently?

jax

135 Posts

I am sorry this has happened - it must have been a horrible 'kick in the stomach ' feeling when you realised what had been done.

I am not familiar with the way facilities work in the US but if it's necessary to float , can you be excused from doing meds, and get someone else to do them? I am very leery of doing any meds when I am not familiar with the unit or patients, and I wont give any meds if until the id situation is rectified. At the risk of sounding very rude there are too many wacky people in the general public who think its funny to pretend to be someone else, or even people with dementia who present well, but after further conversation you realise one of you has missed the bus.

If it's any consolation you'll never do it again. We all make mistakes. Jax

Tweety, BSN, RN

33,525 Posts

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.

The error is 100% your fault. As unfair as that is, it is always the responsibility of the nurse passing the meds, regardless of the reason. I'm not sure what I would have done differently in that situation, honestly might have done the same thing.

However, a good facility will look at the total process and not fry the person making the error. They will use it as a learning tool to improve anything they can to avoid future mishaps. Perhaps that is what you should be doing, rather than looking for whose fault it is.

Sounds like you need to have a sit down one-on-one meeting with the DON to discuss this unit not following protocol and the abusive NP and the conditions leading up to your error.

And maybe think about finding a better and safer job where your license isn't so much on the line. Something serious could have happened.

Mint Julip

76 Posts

A totally unsafe situation. I don't understand why they would leave you on your own on an unfamiliar unit. I think what administration did to you was definitely wrong, but the responsibility for the med error lies with you. You were the one who dispensed the medication. Why did you give the meds if you questioned the identity of the resident? I would of informed the adon that she would have to give the meds herself even if that meant being fired. I would never risk what I have worked so hard to earn...my license. Growing pains or not, they have put you in a precarious position. I feel for you. It's a tough situation to be in.

Brownms46

1 Article; 2,394 Posts

Specializes in Everything except surgery.

WOw what a mess that place sounds like! I know that you wish you had never walk on to that unit that day, but it is situations like this, that I refuse to go to LTC facilities!

When I have went, here is what I did. I would do walking rounds with the nurse giving me report. I never take "short reports", when I don't know the pts. As we go along, they identify the pts, and I write down their location, note what they look like, and how they take their meds. Yes this does bug people who want to tell you, things like, "so and so ok", or " no problems". But it's not them who doesn't know the pt.

There have been times when I arrived after the person who gave report has left, and there is a taped or written report left:eek:!!!

Believe me it is a rare occassion that I take a LTC assignment, but I will grab a CNA to identify a pt., and have a name band put on that pt. right then and there. If no one can tell me who the pt. is, I call another nurse or somebody to identify the pt.

Another reason I have them to do a walking round with me, is that many times the pics are so old, you can't tell for sure if the pic matches the person! Some have loss or gain weight also changing their appearance.

Don't beat yourself up too much, as you say there was no real harm done. But this will just cause you to much more leary the next time. Just MO here....I would be the next person walking out the door, because as you have pointed out, this is an unsafe situation. And another incident waiting to happen! Good luck!:)

Brownms46

1 Article; 2,394 Posts

Specializes in Everything except surgery.
Originally posted by jax

At the risk of sounding very rude there are too many wacky people in the general public who think its funny to pretend to be someone else, or even people with dementia who present well, but after further conversation you realise one of you has missed the bus.

Jax

I don't think that was rude statement at all, in fact it is true in my experiences! The reason why I don't take resident's statement to heart, and will get someone else to verify the pt also!

sjoe

2,099 Posts

Specializes in Corrections, Psych, Med-Surg.

"I currently work in a long term care facility that is going through a difficult growing phase. "

Something tells me this will be a LONG TERM difficult growing phase--like 20 or 30 years. The med error was your fault, of course, but obviously the facility is not interested in doing much to improve a system that is set up to create such errors.

In your position, I would weigh: 1) the value of keeping this job vs. 2) the value of keeping my license. It is no surprise or mystery that the previous managers left. They could see the handwriting on the wall AND the likelihood that things would not soon be getting any better.

nursemommy

5 Posts

Thank you all for your replys. I do agree that the fault ultimately lies with me, but it's good to know that there were contributing factors here. Your right about one thing... I will never make this mistake again!! I like the idea about doing walking rounds. Again, thank you all for your advice.

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