Medication Error in School

[uofanurse]

Please tell me what you think about this:

A parent brought in a refill of clonidine for a student that has taken it since the beginning of the year. The bottle stated clonidine 0.1mg take one tablet at 1100. Correct student name on bottle

Audit was done in my clinic by supervisor. Supervisor told me to pull up drug.com pill identifier and identify each pill I had in my locked drawer. When we got to the clonidine which are white and round, the imprint on it stated it was trazodone (which student is on for sleep) 

Supervisor told me to write up an incident report. I did, I told mom and the Dr. what happened-- that the student was receiving trazodone instead of clonidine. Mom stated she does not know how the wrong med was in the bottle. She stated she was sorry and was not concerned.

I was suspended for 3 days and a formal investigation was performed on me by HR. 

My supervisor also reported me to the board of nursing. I am now awaiting my fate with a lawyer on retainer. 

There is not a policy written to use a pill identifier when intaking meds. supervisor stated it falls within the 5 rights of medication admin. 

HELP! 

[JadedCPN, BSN, RN]

43 minutes ago, Anne Weber said:

I have been a school nurse for 10 years. Never seen a school policy stating for the nurse to verify what the pill actually is. I would have just trusted the parent too.  But they do have you with the 5 rights.

Trust me the school will protect themselves and throw you under the bus.

Good Luck !

How do they have OP with the 5 rights? OP was under the impression that it was the right medication, and the bottle with a pharmacy label confirmed that. Otherwise we all would need to go the extra step of using a random online pill identifier even in the hospital setting to confirm that the label from pharmacy isn’t wrong. 

[Bear92, BSN, PhD, RN]

I sympathize with this nurse. School Nursing is no fluff job.  The demands and amount of work is most often far beyond realistic time frames. Adding on pill identification for every med brought in is not in the job description.  If they want to add to it, they need to add more hours/pay. 

I cannot understand the motivation of the supervisor in reporting to BON an incident that was clearly not the fault of the nurse.  Item 2 in the requirements puts the responsibility clearly on the parents.  This incident was either an error by the parent or the pharmacy.  Yes, I understand that the nurse is the final wall of protection and the medication rights are essential.  But, this is clearly an issue where the follow up should have held the parent or pharmacist responsible.  Why would a nursing supervisor use another nurse as the scapegoat? 

[nurse elaine]

very unfortunate.  It could happen to anyone, and if that were me, I would not have seen that either.  The supervisor did not need to go so far, a write up with no suspension and definitely no report to board would have been more than adequate.  Unfortunately, nurses are rarely backed up or supported vs other professionals who I'm quite sure make mistakes as well.

I understand the feeling, really sorry.  Keep your head held high.  

[Diane Foss, RN]

I cannot see how this would be the nurses fault. If the pills were brought to the school by the parent in a bottle with the patients name and the pill name on it… Then the nurse and no obligation to try and decide , if they were exactly what was in the bottle. The person who put the pills in the bottle is at fault, in my opinion.

[Popoagie, ADN, EMT-P]

On 3/19/2021 at 9:40 AM, uofanurse said:

Please tell me what you think about this:

A parent brought in a refill of clonidine for a student that has taken it since the beginning of the year. The bottle stated clonidine 0.1mg take one tablet at 1100. Correct student name on bottle

Audit was done in my clinic by supervisor. Supervisor told me to pull up drug.com pill identifier and identify each pill I had in my locked drawer. When we got to the clonidine which are white and round, the imprint on it stated it was trazodone (which student is on for sleep) 

Supervisor told me to write up an incident report. I did, I told mom and the Dr. what happened-- that the student was receiving trazodone instead of clonidine. Mom stated she does not know how the wrong med was in the bottle. She stated she was sorry and was not concerned.

I was suspended for 3 days and a formal investigation was performed on me by HR. 

My supervisor also reported me to the board of nursing. I am now awaiting my fate with a lawyer on retainer. 

There is not a policy written to use a pill identifier when intaking meds. supervisor stated it falls within the 5 rights of medication admin. 

HELP! 

Your supervisor sounds like a real peach.    Having been a supervisor who has reported to the BON (nurses diverting drugs).  As you wait, develop a good plan of correction that would help reduce or eliminate this happening again.   Suggestions, parents bring medications bubble packed from pharmacy or supervisor be responsible for opening each med bottle and checking each pill against photo list to make sure they are correct, or she can do it with you....    We are all told and told “incident reports are not punitive, they are to help us find weak spots in the system so we can correct”.  This supervisor used it as a punitive action.   Last, if you can work through some possible plan corrections, you might even consider going as far a sending them to your school board for review.  I doubt this supervisor will like it, but it really doesn’t sound like they are trying to fix a problem, but create one.   Good Luck!!

[nurse elaine]

This kind of treatment is not rare, and it is the reason why we lose wonderful nurses every day.  Ridiculous that this kind of stuff even happens.  I am ashamed of where the medical profession has gone and how poorly nurses are treated.

[londonflo]

On 3/19/2021 at 12:40 PM, uofanurse said:

I was suspended for 3 days and a formal investigation was performed on me by HR. 

I just went back to reread your original post. Are you back at work? I am confused about an employer filing a complaint with BON and still keeping you on? Do you have the results of the formal investigation? Have you thought of going to a labor attorney? 

[uofanurse]

I am back at work. And super scared to be here in lieu of what is going on. I have a lawyer on retainer that is costing me $5000.  I am really thinking about just not coming back because I am afraid of what else they will try to sanction me with. 
I completely agree with you Why have me stay if you think I’m such a horrible nurse to begin with that you had to contact the board for me

[spotangel, DNP, RN, NP]

How can you be made responsible when the  parent sent you the wrong med? Did she get it like that from the pharmacy or did she sent it in another bottle?  Still puzzled! If pharmacy sent it what did they put in the trazodone bottle?

[guest1143647]

Now this is making me nervous as a private duty nurse. How would I know what the parents put in the med bottles?

[amoLucia]

49 minutes ago, spotangel said:

How can you be made responsible when the  parent sent you the wrong med? Did she get it like that from the pharmacy or did she sent it in another bottle?  Still puzzled! If pharmacy sent it what did they put in the trazodone bottle?

My question exactly re the poss med switch!! Maybe it was only the one bottle erroneously filled?

1 minute ago, Runsoncoffee99 said:

Now this is making me nervous as a private duty nurse. How would I know what the parents put in the med bottles?

Now you've got me thinking more ...

[uofanurse]

I received liquid Zyrtec today from a parent and just asked my supervisor how do I identify the liquid in the bottle haven’t heard back yet