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.
Specializes in Med-Surg, Administration, Informatics.
How did I look up pill appearance? We had a PDR that had color photos of all the pills. So if it was a drug new to me, I looked it up before I administered it. Back then (this was in the 1970s) it never happened that the pill appearance changed. I don't know why, it happens all the time now, and usually the pharmacy sends a note with the new pills that the supplier changed. Of course now, I just get out my cell phone and do a drug look-up checking the color, shape, and markings on the pill.
Back then (this was in the 1970s) it never happened that the pill appearance changed. I don't know why, it happens all the time now, and usually the pharmacy sends a note with the new pills that the supplier changed.
Most drug companies hold a patent on the new drug for 20 years (supposedly to get back all the $$ it cost for R & D.) Things changed in the 80's when it became more cost-effective to create generics, after the 20 years had past.
Quote
The floodgates opened in 1984 with the passage of the Drug Price Competition and Patent Term Restoration Act, commonly known as the Hatch-Waxman Act. The FDA calls it "one of the most successful pieces of legislation ever passed."
Before 1984, companies wanting to make a generic had to do the same studies as the brand company, so the cost was high. With the passage of the act above, generic companies just had to show their version has the same ingredients.
Just my two cents. I believe with an investigation, most get a warning for first offenders with no serious injury to the student/patient. Also, it depends upon, repeat nurses, type of medicine, duration received, and the response from the supervisor and family. Meaning if it was an antiacid maybe it would be just a warning from the supervisor. The investigation could be a couple of months or so. If you or the lawyer didn't agree with the outcome at the informal settlement conference, it could go before a public hearing. I think most people would agree that one, the pill does come in a white and round form as the other, and two, the parent caused confusion with an identically-looking pill issued to the clinic. I believe you will be OK but it is scary to go through the process. Realize, that any other prudent nurse could have done the same thing. A sub could have easily done this, not knowing how the previous pill looked. I might would call the pharmacy on the bottle and report it to use as evidence for the board. You could also get another job before it goes through investigation if you think the supervisor has it out for you. Go with your gut feeling.
Quote, "Sounds like supervisor knew something was not right." I wouldn't be surprised to find that the parent or someone else reported you to the supervisor when the error was discovered.
Specializes in Vents, Telemetry, Home Care, Home infusion.
In the good old days 77-79, as night LPN charge nurse, was responsible for med reordering on a 26 bed unit. Meds came in a inside a small cardboard box with slide plastic cover, so one got to learn medication appearance: color, shape, imprint markings quite well. Used Nursing 1999 drug book comparison chart or called pharmacy at7AM when they opened to inquire about changed pill/wrong med suspected.
Fast forward to current times about 1-2x year found wrong med/dose in husbands 20 different RX when prefilling his weekly 4xday med box.
As home health nurse, on admission, new med and recert, I would peak into each pill container to check appearance of med + matched pharmacy label -caught several discrepancies. Home Health Agency got dinged by Joint Commission one year because patient had taken upon herself to place entire days pills into one old pill container for ease carrying with her and Primary Nurse unaware.
1. it's not stated in your workplace's policy to match the individual pills to the description of the label on the bottle.
2. School is an extension of the home environment. As such, are parents checking individual pills on a regular basis?
3. I think it's a setup that the blame is being placed on you. If this is a priority, it should've been the parent's responsibility.
If it were me I absolutely would not take responsibility for this. Of course, if it were a very obvious error like receiving giant Metformin pills in a bottle labeled for clonidine, I could understand why one would pause. But nurses aren't taught to know what each individual pill looks like! Ugh, I hate this for you.
Specializes in Psych, Corrections, Med-Surg, Ambulatory.
On 3/24/2021 at 8:06 AM, nurse elaine said:
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.
What was the nurse's mistake and what would be the legitimate reason for writing her up? The parent brought in a bottle containing different pills from what was on the label. (And then was unconcerned that the bottle contained the wrong pills. What did she already know? Why did the supervisor demand an audit?)
It is an absolutely ridiculous expectation for the nurse to have to routinely ID pills.
Ribbons, BSN, MSN, PhD
16 Posts
How did I look up pill appearance? We had a PDR that had color photos of all the pills. So if it was a drug new to me, I looked it up before I administered it. Back then (this was in the 1970s) it never happened that the pill appearance changed. I don't know why, it happens all the time now, and usually the pharmacy sends a note with the new pills that the supplier changed. Of course now, I just get out my cell phone and do a drug look-up checking the color, shape, and markings on the pill.