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! 

On 3/22/2021 at 2:17 AM, guest1143647 said:

Your supervisor is an idiot. Why would she report you for something that is not even in the policy? It only mentions containers,not actually identifying the pill. I hate overzealous supervisors.

The requirement for a receiving nurse to verify the med received is a good one. 

But it sounds like the Sup never oriented her nurses to this requirement. 

Sounds like the Sup should be held responsible, too, not just the nurse.

 

So who messed up?  The pharmacist?  parent?  is there something  sinister going on - like another nurse did this mix up intentionally????

On 6/5/2021 at 1:11 PM, DCtoRN said:

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!!

They might be happy now but they will turn on you in a heartbeat if you mess up.  Watch your step.

On 3/29/2021 at 11:35 AM, k1p1ssk said:

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.

That would be good, as it would pretty much prevent parents doing something bad with the pills.

Please let us know what your wonderful Sup replies about this.

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