Medication Error in School

Specialties School

Updated:   Published

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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! 

Specializes in Clinical Research, Outpt Women's Health.
1 hour ago, uofanurse said:

There is nothing anywhere that’s stated to use a pill identifier. But here I am in limbo and $5000 poorer. 

Unreal that they did that to you.

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Specializes in School nurse and geriatrics..
On 4/23/2021 at 11:00 AM, uofanurse said:

There is nothing anywhere that’s stated to use a pill identifier. But here I am in limbo and $5000 poorer. 

Well, I check in on this site to see how it is going. I hate that you had to spend one dollar on this. 

1. Child was not harmed,

2. Parent supplied medication.

3. Child was not harmed. ( It needed saying again.)

4. Doctor and parent made aware.

5. I myself have made changes because of this to make certain that I lower my odds of something like this happening and bet you have as well.

Everything else completely unnecessary and costly. 

You stay strong.

Maybe you could write a new continuing education course to help others in the future when this craziness is over.

It makes me wonder what else have we not thought of that could go wrong with the medication we receive on a regular basis???

 

 

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Specializes in school nursing, ortho, trauma.
On 4/23/2021 at 12:00 PM, uofanurse said:

There is nothing anywhere that’s stated to use a pill identifier. But here I am in limbo and $5000 poorer. 

are you in a union?

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Nope ? 

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Specializes in Intensive Care.

Late to the discussion, but  I can sure identify. I was severely disciplined for missing a latex sensitivity (non anaphylactic) in a patient and inserted a latex Foley for which he had to return to the ED the next day to have changed due to skin irritation. While the error was mine and won't ever happen again, there were many contributing circumstances.

Perhaps because I am active in our union, I was thrown under the bus. I live in a small town with few opportunities outside the hospital and SNFs. Within the hospital, there were few options to move forward (my ED orientation was terminated and I was returned to MedSurg).

A new position for school nurse was posted just at the right time and I WAS HIRED!! I gave notice to my manager at the hospital yesterday, the day I signed my contract with the school district.

My advice to any nurse going through what you or I went through is to GET OUT!! Hopefully you are in an area with more options than I had and won't need a small miracle like I had, but in my mind, staying at a place that treats nurses like this is putting our own career in jeopardy.

Thankfully, my board doesn't post investigations in process. The investigator said my case will be dismissed, but the board is backlogged and it's been 6 months!

Hang in there (but don't hang around!) Nurses are in demand- you are valuable.

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Specializes in kids.

When this is all said and done, and you are exonerated...as I suspect you will be, I would very carefully consider suing for damages (5k) plus attorney fees for the suit.

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Specializes in school nurse, hospice, OB.

It is indeed a sad state that nurses are in.  Any one of us can, and will, make a mistake.  Any other profession allows for human error, and most professionals have some type of representation or someone to back them up.  I have had multiple bad experiences with both employers, and, unfortunately, other nurses.  If you are accused of anything, it is guilty until proven innocent.  We are taught to treat others with dignity and respect.  We put others needs before our own.  Yet when the chips are down, expect to be thrown under the bus.  Wow!  That makes me very, very sad.  I am so happy to be working in a school environment where I feel loved and safe.  If I had to work in some of my prior environments, I would consider leaving the nursing profession altogether.  After 32 years.  I have been a hospice nurse, an OB nurse, a health department nurse, hospital nurse.  I have held hands of hundreds of patients during times of both joy and sadness.  I have put the needs of my patients/clients/residents above the needs of my own, and above the needs of time with my family, only to be betrayed by my own profession.  It is no wonder that the nursing shortage is so great.  I have made a decision to work where I get about 1/2 of my prior income, and I am very happy that I did it.  I refuse to work under other circumstances, I refuse to let others hold me hostage with a constant fear of reprimands, fear of loss of job or unfair treatment.  I am more valuable than that.  I am ashamed of the medical field's treatment of nurses. I have witnessed unbelievable emotional trauma felt by some of the best nurses I know.  I don't see it changing any time soon.  Remember fellow nurses- you are valuable.  You are important.  You deserve to be treated with the same respect and dignity that you give every day to others.  Don't stay somewhere feeling stressed and uncared for.  Let's support each other as much as possible.  Only another nurse knows what we go through every day.  I hope you are all having a good day, love and hugs to my fellow warriors. 

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Specializes in Intensive Care.
On 6/3/2021 at 6:13 AM, nurse elaine said:

It is indeed a sad state that nurses are in.  Any one of us can, and will, make a mistake.  Any other profession allows for human error, and most professionals have some type of representation or someone to back them up.  I have had multiple bad experiences with both employers, and, unfortunately, other nurses.  If you are accused of anything, it is guilty until proven innocent.  We are taught to treat others with dignity and respect.  We put others needs before our own.  Yet when the chips are down, expect to be thrown under the bus.  Wow!  That makes me very, very sad.  I am so happy to be working in a school environment where I feel loved and safe.  If I had to work in some of my prior environments, I would consider leaving the nursing profession altogether.  After 32 years.  I have been a hospice nurse, an OB nurse, a health department nurse, hospital nurse.  I have held hands of hundreds of patients during times of both joy and sadness.  I have put the needs of my patients/clients/residents above the needs of my own, and above the needs of time with my family, only to be betrayed by my own profession.  It is no wonder that the nursing shortage is so great.  I have made a decision to work where I get about 1/2 of my prior income, and I am very happy that I did it.  I refuse to work under other circumstances, I refuse to let others hold me hostage with a constant fear of reprimands, fear of loss of job or unfair treatment.  I am more valuable than that.  I am ashamed of the medical field's treatment of nurses. I have witnessed unbelievable emotional trauma felt by some of the best nurses I know.  I don't see it changing any time soon.  Remember fellow nurses- you are valuable.  You are important.  You deserve to be treated with the same respect and dignity that you give every day to others.  Don't stay somewhere feeling stressed and uncared for.  Let's support each other as much as possible.  Only another nurse knows what we go through every day.  I hope you are all having a good day, love and hugs to my fellow warriors. 

Amen! Particularly in the hospital setting, nurses seem to unconditionally tolerate extreme working conditions and abuse in the name of sacrifice for the healing of patients. Patient care and stressed out nurses are not compatible!

I am so grateful to be venturing outside the hospital and into school nursing. I expect a steep learning curve, having no school nursing experience and being the only nurse in a 1300 student district, but I am great at finding and using resources, asking questions, receiving constructive input, etc. Plus, this district hasn't had an on-location nurse other than an occasional contract nurse for over a decade. They are so happy to have a warm body and they are especially happy to have me joining them (small town- we mostly know each other from my parenting and coaching presence).

Be strong nurses!!

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Is there any update to this thread?  I haven't been on here for a while and am wondering if I missed what ended up happening. This sounds totally malicious to me.

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I am just now reading this and wonder what the outcome is. 

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I'm sorry you're going through this very stressful situation. The only thing that I can see being a problem is if the bottle the parent gave you was not exactly as is stated in number 2 of the policy shown. 

Our policy in my district and throughout the city for school nurses is that no medication can be accepted unless it's in the pharmacy bottle it came in, pharmacy driven label, name, dose, med, time, expiration date, physician, etc. Anything less goes back home with the parent and I'd notify the supervisor.

So, not to be discouraging, it's not that. But I want to mention that crucial number 2 listed in the policy that's posted in this thread. If the bottle didn't measure up to policy then that's going to be the issue. If the bottle does measure up to policy, then they're wrong.

I hope it will eventually be resolved in a good way for you and that you'll move forward in the best way. Things do go wrong at work sometimes, and usually, hopefully!!, there's understanding about what happened. 

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Hi,

I work with kids in an residential psych facility where we often receive medications from home when a client admits. We complete a form for medication reconciliation, and my standard is that I check to ensure the name and medication is correct, the med is not expired, and also check to be sure the medication description on the bottle matches every pill in the bottle. It is surprising how often parents will mix medications in bottles. If the school's process for receiving medication does not include that check, it seems that should be added to the policy. It appears from the pic that the parents take liability for the medications they bring, and this should be pointed out by your legal representative. 

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