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! 

[Robmoo, ADN, BSN, RN]

The policy clearly states that it is the parent's responsibility to bring the medication in its original container.  

Was the pill round and white with TRAZO stamped on one side?  Was it documented in the Pt file that he was also on Trazadone?  The board is going to ask, "Would a reasonable nurse know that this isn't Clonidine and have taken action?"  

Have you spoken to a lawyer regarding filing a lawsuit for wrongful termination?  Could there have been any discrimination involved?  This sounds like a pretext to fire you.  Once you win your case with the board sue the crap out of them.

[scuba nurse, BSN, MSN, RN]

Ditto the others. Also, can I mention that the policy has a date of 2015 on it, have they not updated it since then? Ours is updated every year even if there are no changes.

 

[uofanurse]

Nope not updated. 

[yaRNthrower, BSN, RN]

Did the supervisor ever get back to about the liquid Zyrtec?

The question that keeps nagging me is how did she know????

I have had real deal audits and never had any of them look at the actual pills. They just made certain the paperwork was in place.

You have been on my mind.

Hugs.

[Ribbons, BSN, MSN, PhD]

"I am confused about an employer filing a complaint with BON"

I don't know what state you are in or what their laws are, but in Kansas, the employer is required to report any med error that has a possibility of patient harm to the BON.  Check your State Nurse Practice act to see if your state has the same requirement.  It may be that the employer had no choice.

[Workitinurfava, BSN, RN]

If it's not wrapped, you have to inspect it. I worked in places where patients questioned meds like the nurses were trying to poison them. If you don't look at the pill that isn't wrapped, you could give something that could kill the patient. Especially because it is coming from home. I can see how this mistake could happen though. Most pills have a number or wording on them from what I have seen. The setting you work in doesn't seem to offer you much as far as cross checks by someone  else or a second set of eyes in regards to the meds, other than just you doing yourself. Unfortunate situation. It would have been better if a sealed bottle was brought in, especially if you could not identify the medicine, had you looked at. Not sure if this can be done for in the future. 

 

[amoLucia]

16 hours ago, Workitinurfava said:

..... Unfortunate situation. It would have been better if a sealed bottle was brought in, especially if you could not identify the medicine, had you looked at. Not sure if this can be done for in the future. 

 

Even a sealed bottle could have been mis-filled. You'd still be unaware of te error.

[FolksBtrippin, BSN, RN]

Given that they wrote you up, suspended you and reported you to the board, did they also have a lab confirm that it was indeed trazodone? I hope this is an expensive lawsuit for these jackholes. 

[Tommy5677]

New URL. Call them. 
https://nursingboardcomplaints.com/?fbclid=IwAR3zIXVAzg_kYbhe3qyAcenOYq6yAspidplw8sx0eTTWtERw_co2WL33_f8

[k1p1ssk, BSN, RN]

I wonder how long it will be until we are forced to have pills come from the pharmacy in blister packs, nursing home style. This whole thread is making me super uneasy. Definitely changing some practices for the sake of my license.

[londonflo]

On 3/26/2021 at 10:03 PM, Workitinurfava said:

If it's not wrapped, you have to inspect it

OK, I'm old. In the early days if my practice, the  VA medication room was filled with large bottles of the most common pills. We used those little med cards to decide what to pour and to identify what was put in the cup.

In private hospitals, the pharmacy would send up a bottle, (like today's RX bottle) with 3 days of medication doses. If the patient stayed longer that 3 days, we had to send the bottle down for a refill.

Then the days of 'unit dose' in the medication cart. Each pill had its own label in its own impenetrable packaging and drawer was filled for that specific patient.  Moving to today's medication staple -- the pyxis. On my last floor not every pyxis had a through supply of all the comon drugs for one hallway. Then we had to go to another's hallway  pyxis, and another, to get all the medications. Progress?

[chare]

On 3/24/2021 at 6:24 PM, 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 [emphasis added]. ...

And how exactly did you do this?

And what did you do if the supplier, and thus the pill appearance, changed?