Med Error.

Been there,done that, ASN, RN · Mar 18, 2014

"should've recognized that he was using a wrong parameter".

Please clarify... do you mean the pharmacist? If so the pharmacist made the error.

NC29mom, ASN, LPN, RN · Mar 18, 2014

"should've recognized that he was using a wrong parameter".
Please clarify... do you mean the pharmacist? If so the pharmacist made the error.

Not if the nurse administered.....

I wish you the best and hope your manager is understanding. We are human, not perfect by any stretch of the imagination. Errors happen....its just life. If she does fire you, consider it a new chapter in your life (I know, easier said than done). I found my dream job after being fired. Was really upset for a long time, but realized it was meant to be. I'm soooooooooooooooo much happier now!!!!!

Hugs & prayers

Gabby-RN · Mar 18, 2014

Not if the nurse administered..... I wish you the best and hope your manager is understanding. We are human not perfect by any stretch of the imagination. Errors happen....its just life. If she does fire you, consider it a new chapter in your life (I know, easier said than done). I found my dream job after being fired. Was really upset for a long time, but realized it was meant to be. I'm soooooooooooooooo much happier now!!!!! Hugs & prayers[/quote']
It seems as though The pharmacist and the nurse both made the error. The pharmacist either made a dispensing error or a transcription error depending on the specific circumstances. The nurse made an administration error if they were responsible for verifying the dose was correct/safe dose and it was not. For argument sake say the nurse administered Tylenol 325mg for a fever because that is what the order in the computer said and the pharmacist had actually transcribed the doctors order for Tylenol 650mg incorrectly. Did the nurse actually make a med error because the usual dose is 650mg? If the nurse gave 6500mg because the order in the computer said so, I would say yes that is an error because the nurse should know that dose is not safe, but an under dose that was a written order? I feel like there is some grey area there and at the very least the nurse is not solely liable.

FineAgain · Mar 19, 2014

We have a double check system for Heparin and Insulin; we look up the labs ourselves, go to the "calculator" in our protocol. The other RN looks at it with us, checks the pump settings after the change, and signs it off on the MAR. Really helps prevent things like this from happening. Hugs to you.

HouTx, BSN, MSN, EdD · Mar 19, 2014

Have you analyzed the issues behind your med errors and changed your behavior accordingly? For instance, if you are rushing through the process & not taking time for the '5 rights', you probably need to deliberately slow down & remove yourself from distractions. None of us is perfect. People who learn from their mistakes have the potential to become experts. People who do not learn from mistakes just keep on repeating "year one" over and over again.

hope3456, ASN, RN · Mar 19, 2014

It could be that you are working in an unsafe "system." I don't see why you have to take a the blame.

psu_213, BSN, RN · Mar 19, 2014

I don't really like when these discussions turn into "who is to blame?" but that seems to be where this one is going. I think both the nurse and the pharmacist is at fault. I'm not sure of the exact system your hospital has in place, but let's say that the pharmacist gets the lab result and makes a communication of adjust the drip by X" (or "keep the drip at the same rate"). Then the pharmacist is at some fault for the error. I think this is also a system error, as this doesn't seem like the best way of doing things.

However, it is also partially the fault of the nurse who is actually adjusting the drip. Not be "high horse" about it, but if I am adjust a drip of a "high alert" med, I am going to make sure that the correct adjustment is being made based on the lab work and the clinical picture.

TU RN, DNP, CRNA · Mar 19, 2014

Is this even a med error? I could understand if you gave the person an insanely high amount of heparin and they bled, but too little and they have to be on the drip longer before they can transition AC? It seems excessive to call that a med error. People are sub-therapeutic with the ordered nomogram where I work all the time - it's just the way it goes. I know if you look at it per the nurse's 5 rights, it was an error. Looking at it from a medical standpoint, I don't think you affected the patient that adversely.

I have heard of hospitals where heparin drips are completely managed by physicians. They order the bolus (if needed) and initial rate. They order the regular PTTs and call to make sure they've been drawn. Then they check those values and call to be sure the rate is changed, per the calculations they do on their own. A union hospital this is.

Where I work the nurse does it all, even so far as reordering PTTs q6h (with physician cosign required), looking up values, calculating rate changes based on previous rate and patient's weight, and then making those changes with a witness RN to check all of the above.

toomuchbaloney · Mar 19, 2014

I don't really like when these discussions turn into "who is to blame?" but that seems to be where this one is going. I think both the nurse and the pharmacist is at fault. I'm not sure of the exact system your hospital has in place, but let's say that the pharmacist gets the lab result and makes a communication of adjust the drip by X" (or "keep the drip at the same rate"). Then the pharmacist is at some fault for the error. I think this is also a system error, as this doesn't seem like the best way of doing things.
However, it is also partially the fault of the nurse who is actually adjusting the drip. Not be "high horse" about it, but if I am adjust a drip of a "high alert" med, I am going to make sure that the correct adjustment is being made based on the lab work and the clinical picture.

Of course it comes down to "who is to blame", the nurse will at minimum be reprimanded and at worst be terminated because she "is to blame" and will be held accountable.

What would be more constructive would be a discussion of what processes lead to the error with the goal of improving the processes.

How does it work where you work?

psu_213, BSN, RN · Mar 20, 2014

Of course it comes down to "who is to blame", the nurse will at minimum be reprimanded and at worst be terminated because she "is to blame" and will be held accountable.
What would be more constructive would be a discussion of what processes lead to the error with the goal of improving the processes.
How does it work where you work?

I very much agree that the discussion needs to be about why the error was made, not just which person made it. Who orders the lab draw? Does only the pharmacist get the result? If the nurse gets it to, he/she should be on board with any rate changes.

Also, are you asking how med errors are investigated at my hospital? I don't know. Thank the Lord that I have never been the target of said investigation. Also, if the nurse in question has made multiple med errors, I would imagine that, fair or not, greater scrutiny is going to be focused on that nurse. Hopefully such scrutiny will center on "what can be done to help the nurse prevent errors in the future"; not "let's hang this nurse out to dry."

toomuchbaloney · Mar 21, 2014

well, I guess I was asking anyone/everyone as not all employers handle these issues the same way.