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Discussion

3 Med Errors in One Shift

I know medication errors happen. We are human. As a newer nurse I am not naive enough to believe it will never happen to me. With that said I am concerned and upset about a PRN nurse that made 3 med errors in one shift. Let me know if I am being wrong in thinking like this.

Without giving to many specifics, this nurse gave a anti hypertensive with specific parameters ordered. The nurse did not check BP/Apical pulse, nor did she have an aid do it prior to giving the med. The resident is known, and it is very well documented that this person often falls below the parameters ordered for this drug. So it is often held.

The other 2 were with giving a wrong narcotic, and then a wrong dose of a narcotic.

These errors can not even be blamed on a system error. All the orders in the MAR are written correctly, and clearly, and the name of the resident with the correct script are written correctly on the drug card. These were not new orders either. The narcotics in the lock box are even separated by resident's name and time. All of these were written up by the charge nurse as incident reports. (They were all caught at change of shift report/ narc count). There was no adverse effects to the residents from these errors

To me this is a red flag that this nurse was either impaired, or just truly unsafe. The DON still has her scheduled for PRN shifts. I don't know, I'm just perplexed by the situation.

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    If she was written up and counseled I am not sure what else you can do. Offer to help. Keep a close eye when you can. But anyone can have an off day, even one that off. I am not excusing it, as it sounds like it could have been pretty dangerous, but truthfully it isn't your job to worry about her performance. If you SEE her behaving in an impaired manner it would be one thing. But if all you saw were these med errors and management is aware and taking action according to the company guidelines, you need to stay out of it. Use it to learn about monitoring your own med passes and let it go. Discipline for mistakes is about the mistake, yes, but when management is good, it is also put into context of the person's history as a nurse and their history with the company.

    Try to not judge your fellow nurses too harshly. You never know when it will be you on the other side of the situation and you will be worried about what others think, feeling badly about yourself, feeling guilty and praying for compassion from your fellow nurses. Extend her some grace.

    To say that because the MAR was accurate it couldn't be a system error is not true in any case. Staffing, work load, familiarity with said MAR and said "system", fatigue, burn out, number of and depth of interruptions during med pass and other things all play in. It is very, very rare that a med error is just a stupid nurse. There are almost always other factors. Yes, impairment is one potential factor but you did not mention anything that would cause you to jump to that conclusion and it is unfair and ungenerous of you to do so. To chalk it up to her being "just truly unsafe" is also unfair. I am going to go out on a limb and say you probably know nothing about this person. To look at one aspect of someone's personal practice and deride them as either impaired or just uncaring/careless/stupid/criminal is unkind at best. She made several mistakes, all in one night. Of course that is concerning and something that should be addressed. From what you said, it has been. Were you hoping they would fire her?

    You didn't mention if they were all on the same patient or not, nor did you mention the general conditions she was working under, her level of organization, whether she was struggling with anything, how long she has been with the facility, how often her PRN shifts are, how much help she had, what the general culture is at your facility, whether she is well respected there, how she interacts with other coworkers, how she reacted to her errors and whether you offered to help her at all.

    Be wary of lynch mob mentality, young nurse. It can easily be you on the other side of the noose and all it takes, as you have observed, is one bad night. I would gently suggest you read up on root cause analysis and use some of those techniques to evaluate what happened if you are truly disturbed. At worst you gain a little insight into what causes medical errors and at best you may find info useful to your facility that you can then present to help improve the system.

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    How did you know that she did not get the B/P and pulse or have an aide do it?

    Where you there watching her?

    What was you expectation that this nurse get fired for the med errors?

    The meds might have been labeled and locked, maybe those two narcotics errors she mixed up the cards and was one error affecting 2 patients? She is PRN, doubt she knows the residents as well as a full time staffer

    How do you know she is unsafe? Because the med errors?

    If that is your reasoning then every nurse is unsafe, because every nurse will eventually make a med error....even you

    I bet that nurse after having 3 in one shift, is already beating herself up.

    How about next time you work with her, ask her if she needs help with anything, but save the judgement, because one day it could be you

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    Yea I agree with the above posters but want to also reinforce the idea of being supportive. SO important for working with a team. (As a side note this goes for everyone in the building, not just nurses.) That support will come back to you ten fold someday! My thinking is that If she's per diem she may have been overwhelmed not being used to the routine on a daily basis . Maybe this isn't the case , it usually takes me a very long time to stop giving people the benefit of the doubt and even then, it's up to management to decide on best course of action. That being said , if I personally catch someone in the act of being unsafe , I do try to address it with the person and possibly management.

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    I am in agreement with the other posters. Someday your co-workers may be talking (or posting on a website) about you and saying "What was she thinking? I think she was impaired."

    So many nurses today have compassion for their patients, but none for their fellow nurses. It's a sad state of affairs.

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    Actually there are "adverse affects" to the patient. They received a medication they should not have or they did not get the medication they were supposed to. If you mean they are not dead then yes..I guess that is good. Any med error means the patient was subjected to something they should not have been.

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    • Experts

    I found that in LTC facilities certain PRN nurses are often given leeway due to their special relationships that got them hired in the first place. Not saying this is in place here, only that I have seen this often.

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    In my state - if this was one nurse with 3 documented med errors in one day - it would have to be sent to formal Peer Review for them to sort out. If they identified a pattern of behavior, it would have to be reported to BON.

    If we've ruled out extraneous / system factors, I don't think we're doing any favors by trying to come up with additional excuses for poor performance.... everybody has a bad day once in a while, but we cannot allow it to affect our patient care. It's as though we're saying "you poor thing, you just aren't as good as the rest of us so we don't really expect you to perform as well as we do". That's disrespect.

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    To me this is a red flag that this nurse was either impaired, or just truly unsafe. The DON still has her scheduled for PRN shifts. I don't know, I'm just perplexed by the situation.

    I think you are making quite a jump with the assumptions about why the errors were made. Could she have just been having a bad day? When she gave the wrong narc, was she just being pulled 10 other different directions? Yes, she should check the BP before given the antihypertensive, but, as someone else said, how do you know she didn't? How do you know any of the circumstances around these med errors?

    You are human. You will make a med error. Maybe you will make more than one on one given day. I'm pretty sure you would not want a fellow nurse to assume you are impaired and/or unsafe, and have that other nurse be perplexed that you even work there. I think you colleague deserves better from a fellow professional.

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    • Author

    Thank you for your input. I'll clarify some things that your responses asked. I was part of the RCA which is how I got involved in this, and I have previous RCA experience. Basically everything was broken down ( how often worked, staffing, environment of the hall the nurse worked, interruptions, etc) pharmacy was involved due to narcotics.

    Long story short. Unfortunately it could not point to a system failure. Hence why I was perplexed. This nurse though only PRN status, picks up 1-2x's a week. Works the same hall/ same resident's. It's a LTC hall with only 12 resident's. It's basically a straight med pass hall, no trachs, tube feeds, IVs. Treatments very light. Had 1 1/2 CNAs. The errors were on 3 different resident's

    I do not work with this nurse. I am on the skilled part. I am by no means starting a "lynch mob" mentality against her. I do not speak of it with other nurses. Yes I am a newer nurse, but I would not act unprofessional towards her. I'm sorry if my original post came off the wrong way. I was trying to be discreet but give details so people could get a picture of it. Yes stating she could have been impaired or truly unsafe was a poor choice of words.

    I did learn a lot from this experience. And I'm glad my DON asked me to be apart of the RCA. I did find out this nurse was let go the other day, and that there were Previous issues prior to this incident. I wish her no ill will and that whatever is going on in her life she gets the help she needs.

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    Actually there are "adverse affects" to the patient. They received a medication they should not have or they did not get the medication they were supposed to. If you mean they are not dead then yes..I guess that is good. Any med error means the patient was subjected to something they should not have been.

    Adverse effect: A harmful or abnormal result. An adverse effect may be caused by administration of a medication or by exposure to a chemical and be indicated by an untoward result such as by illness or death.

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