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Discussion

Medication Error in School

school-nurse-suspended-gave-student-wrong-medicine-provided-by-mom.jpg.97d22fb038e8de534328a093f3e72cd4.jpg

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! 

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    • Featured Replies

    I am unfamiliar with the spectrum of school nursing. I did Google the standards of school nursing practice and found the ANA and the National Association of School Nurses have published this: School Nursing: Scope and Standards of Practice 3rd Edition. if you don't have a copy it might be a good idea to read it and see if the situation you are in is described.

     

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    • Experts

    Darn tootin' I'm checking my meds from now on.

    OK it is the 5 rights - "Right Medication". however it does not say to look it up on drugs.com. 

    Checked my supply I'm good ?

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    • Author

    I just read the book school nursing and scope and standards of practice I also have read several articles outlining medication errors no where and I mean NO WHERE does it state that a pill identifier is to be utilized to administer the right medication 

    17 hours ago, londonflo said:

    Is it a usual act to 'audit' medications that have been brought in? Sounds like supervisor knew something was not right. 

    Is the school ready to send all home medications to a pharmacist to be checked?

    If the parents are not considered reliable to send the correct medication to school another procedure should be established. Is the school ready to make a requirement that all medications that are to be adminstered by the school nurse, must be supplied directly from the phamacist.?

    What about insulin? are you to send it to a lab for chemical analysis before adminstration?

    I love the insulin comment !

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    22 minutes ago, uofanurse said:

    I just read the book school nursing and scope and standards of practice

    Legally we are held to the standards of our specialty. I cannot believe the BON complaint will go anywhere. 

    I was thinking you may have legal grounds after all this is over to file a  harassment and slander claim. Basically this supervisor is saying you are incompetent and is threatening your livelihood.  School districts are always ready to pay to get school superintendents who they wronged to go away. Don't be afraid to demand compensation when this is over.

    Also, can the supervisor contact the BON without reviewing that action with legal counsel and HR? Sounds like there is a loose cannon there.

    Best wishes for you. I am very sorry you have to go through this.

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    On 3/22/2021 at 9:26 AM, uofanurse said:

    Will keep y’all posted. Apparently it can take up to a year for the BON to investigate 

    uofanurse this whole thing says loads more about the supervisor than you.

    I have never doubted a medication that was brought to me in the pharmacy bottle. I have worked in several districts and have never been instructed per policy to use the pill identifier. I'd be right there with you.  I will check from now on as a result of your experience.

    Little round white pills.

    I truly am not a litigious or vengeful person, however, I hope your lawyer has an absolute field day with your supervisor.

    Ay Dios mio.

    Nothing but positive vibes coming your way.

     

     

     

     

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    Bullet point 2 absolves you from guilt in my opinion. Hopefully you have nurse practice insurance (we all should always). Perhaps you can get legal aid through your insurance? It sounds like you were wrongfully suspended to me and that's loss of wages. At my clinic patients that bring their own meds sign a non tamper waiver. Hopefully there is something similar for parents bringing meds?

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    That is ridiculous. Hope things work out for you.

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    As some states have strict rules on what non-pharmacist health care providers are allowed to do, you might visit your state's board of pharmacy website.

    Best wishes.

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    11 minutes ago, chare said:

    As some states have strict rules on what non-pharmacist health care providers are allowed to do, you might visit your state's board of pharmacy website.

    Best wishes.

    True, but one would think that DOE rules and Nurse  Practice Acts would be aligned for the school districts to develop their policies. A school district can have tighter regulations but not looser than what is allowed at the state level.

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    I have been a school nurse for 10 years. Never seen a school policy stating for the nurse to verify what the pill actually is. I would have just trusted the parent too.  But they do have you with the 5 rights.

    Trust me the school will protect themselves and throw you under the bus.

    Good Luck !

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    Holy Cow Bells!

    My heart hurts for you in this situation.

    Also, I completely agree with @londonflo.  

    On 3/22/2021 at 7:23 PM, londonflo said:

    Is it a usual act to 'audit' medications that have been brought in? Sounds like supervisor knew something was not right. 

     

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    • Experts
    43 minutes ago, Anne Weber said:

    I have been a school nurse for 10 years. Never seen a school policy stating for the nurse to verify what the pill actually is. I would have just trusted the parent too.  But they do have you with the 5 rights.

    Trust me the school will protect themselves and throw you under the bus.

    Good Luck !

    How do they have OP with the 5 rights? OP was under the impression that it was the right medication, and the bottle with a pharmacy label confirmed that. Otherwise we all would need to go the extra step of using a random online pill identifier even in the hospital setting to confirm that the label from pharmacy isn’t wrong. 

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