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! 

[Delancree]

Hi,

Public school nurse in a big city here.

I read your policy and it does not state whether or not the medication container may be accepted “opened”. The policy we have at my health agency has that part written in bold. 
I don’t remember being taught in nursing school/pharm. to know the physical characteristics of tabs/capsules etc... This is definitely not part of the med. rights. Unless of course, it is a clause in your policy . The same exact drug may look totally different depending on the manufacturer.  This is wrong of your sup, on every level, and you should fight harder for your rights/license. 

[Delancree]

Unless an opened container was given to you by the parent (which you are not permitted to accept as per policy), or, on inspection you noted something “off” clearly written on the med & you did not bother to check it out, then you cannot be held accountable for this blatant display of lack of knowledge, professionalism and leadership from your sup. ?‍♀️

[amoLucia]

22 minutes ago, Delancree said:

.....  The same exact drug may look totally different depending on the manufacturer.  This is wrong of your sup, on every level, and you should fight harder for your rights/license. 

I receive my personal meds from a large mail-in/phone-in supplier thru my commercial insurance provider. Coreg 3.125 and lasix 20 change by diff manufacturers, alternating between itty, bitty white round pills and white itty, bitty ovals. Several times, both generic meds have changed from one shape to the other.

I rely on the pharm to be correct, but the switches have NOT gone unnoticed. I never get any memos. So it is just my awareness that catches the switches.

[tining, BSN, RN]

The tiny description of the pill on the pharmacy label and the pill matching that description should cover the "Right Medication" in the 5 rights.  Maybe asking the parent to not remove from stapled pharmacy bag would be another option.

I wonder if parent or pharmacy mistake.

[uofanurse]

Here is the policy :

 

[Delancree]

@tining  you are right about the pharmacy label with a description of the pill and all...if you get one. Some of the pills I receive are dispensed in orange tubes with regular sticker labels. Almost all my kids have the same community providers and same neighborhood pharmacies...imagine that. Meds that come in original packages have to be unopened, but with the orange tubes, I just have to trust the pharmacy, the good intention of the parents and my guts. 

[Ribbons, BSN, MSN, PhD]

It is possible that the wrong drug was put in the container by the pharmacist, not the parent.  When working in a hospital, I checked all the pills for correctness until I knew exactly what they should look like.  A couple of times, I had to call the pharmacy and tell them that what they sent up was not the same thing as they marked on the bottle of pills.  Pharmacists are human too, and they make mistakes.  Part of drug safety is the nurse knowing that what we are giving is what we think we are giving.  Of course we can't do anything but trust what is in an insulin bottle--but that usually comes directly from the manufacturer.  The pharmacist doesn't put the insulin in the injector or vial--the factory does.  If the factory put the wrong drug in a vial, the nurse couldn't be held responsible unless something was obviously wrong like the wrong color or perhaps if it was very viscous instead of thin like water.  Anyway, the 5 rights do say "the right drug." But unless the name of the drug (rather than a code) is what was imprinted on the drug, this one might be difficult to argue--possibly on both sides!

[londonflo]

6 hours ago, londonflo said:

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? 

I suggest you talk to a labor attorney. I am not one to rush to lawyers or look for ways to sue but I gotta say, this supervisor (organization) employed a threat to your livelihood....you are innocent, have followed the school's directions to the letter and your actions were within your scope of practice and followed scrupulously. Even if you leave you will worry about references. Talk to a labor attorney if only to find out YOUR rights and if you leave the position, help the next nurse navigate this situation. 

I have never sued someone in my life but these are extenuating circumstances that threatened your professional reputation and livelihood. What is the supervisor's title or area of supervision?

[spotangel, DNP, RN, NP]

1 hour ago, Ribbons said:

It is possible that the wrong drug was put in the container by the pharmacist, not the parent.  When working in a hospital, I checked all the pills for correctness until I knew exactly what they should look like.  A couple of times, I had to call the pharmacy and tell them that what they sent up was not the same thing as they marked on the bottle of pills.  Pharmacists are human too, and they make mistakes.  Part of drug safety is the nurse knowing that what we are giving is what we think we are giving.  Of course we can't do anything but trust what is in an insulin bottle--but that usually comes directly from the manufacturer.  The pharmacist doesn't put the insulin in the injector or vial--the factory does.  If the factory put the wrong drug in a vial, the nurse couldn't be held responsible unless something was obviously wrong like the wrong color or perhaps if it was very viscous instead of thin like water.  Anyway, the 5 rights do say "the right drug." But unless the name of the drug (rather than a code) is what was imprinted on the drug, this one might be difficult to argue--possibly on both sides!

I agree. One time in the clinic, I did a medication reconciliation and found that the pills inside  a new bottle was marked 10 mg instead of 100 mg  Metoprolol-------the patient's BP was always high. The pharmacist apologized profusely. My patient now opens every bottle and checks before he goes home. It might be worth a shot to check with the pharmacy or ask mom to bring in the other medication bottle so you could check if that one is clonidine----either way I would clarify with the pharmacy unless mom told you that she sent some clonidine in another bottle to school.

Hope things get resolved. Hugs!!

[calisss]

5 hours ago, uofanurse said:

Here is the policy :

 

Too many jobs out there for nurses, I would quit that place, not sure how long you have worked there but I would seriously quit, if that's how theyre going to act with you and the supervisor is an idiot. I hope your lawyer is a good one because no way they can hold you responsible and that school should be protecting you because if you get in trouble, they will too I can assure you that so it would behoove them to protect you.

[nurse elaine]

I made a decision early on in my career (will be 32 years in May) that I would not live in fear of litigation.  That being said, I have been fired twice and once 2 coworkers tried to get me fired by lying.  I have been very close to not working as a nurse at all.  

Then...I think about how important our job is.  Patients, families, children, dying hospice clients, the unborn babies...ALL the people we care for every day NEED us, and I am too stubborn to quit.  Is it fair?  no way.  I have left places of unemployment because I knew it would not ever change and I deserved respect and fairness.  I would say when it reaches this point, looking for a place that will appreciate you and not throw you under the bus is a good idea.  But always hold your head high, don't let them see you get upset (if you can, I can't always hold it together but I try), and be proud of how you remain professional, even when others don't.  

We are way more valuable than we realize.  People who we care for remember us for their lifetime.  And we remember them.  Fight on, not for this job, but for your own sense of pride and accomplishment.  You are a nurse, a keeper of hearts, a master of comfort and healing.  

ROCK ON!

[Tommy5677]

So sorry. Trust me when I tell you that boards of nursing are like dogs with bones and they will stop at nothing until they destroy you. I know. I went up against a bone-chewing board and I won but I had help and I'm going to give you a website for the person that helped me. She's in Texas but don't let that scare you. Contact her please. Her name is Darlene Nelson and here it is. And shame on that supervisor for reporting you to the board. If every nurse making a med error was reported to the board we would have no nurses. Any nurse that tells you they have never made a med error isn't being honest. I would also investigate the super to be sure it wasn't an act of malice because that is an offense also punishable by a board, if you can prove it:

https://www.expertnurseconsultants.com/