Medication Error

[jenna84]

Hello,

I made an medication error.

The longterm care centre that I am working asked me to pour the pills to unlabelled dosette.

I poured wrong patient's medication to the dosette during the night shift.

And a different day shift nurse gave the dosette to the resident.

Luckily, the resident recognized that the pills look different and did not take the pills.

Since the work setting is a government running long tern care centre, I might get a phone call from the administrative;however, the manager is telling me that she can also report me to the nursing college for not doing my job correctly ie. checking 5Rs.

Another nurse told me that they should not report me for this because the resident did not actually take the pills. So it is more like a near miss incident.

Can I be reported to the college for this incident?

Please let me know.

Thank you.

[Wave Watcher]

"The longterm care centre that I am working asked me to pour the pills to unlabelled dosette.

I poured wrong patient's medication to the dosette during the night shift.

And a different day shift nurse gave the dosette to the resident."

I would NEVER give pills to anyone if I did not pull them myself. I can't believe that's the way they do it there. You have no way to know what your giving. They need to re-evaluate how they do things. This is an accident waiting to happen on all ends.

If the day shift Nurse could actually check each pill and know what it is (and SHE SHOULD!)....then she could check the MAR....if she could have done that then she would have noticed it was for the wrong patient.

Makes my stomach turn.

I hope all works out for you and I would hope their policy would change....sooner than later.

[Blue Crab Lover]

I am almost certain all boards of nursing forbid pre pouring medications. Especially when you are not the one giving the medication.

[FLArn]

If this is a pill minder that is given to the resident for use while out on LOA the pharmacy should fill it and label it for the patient to use when out of the facility. Otherwise, I am not sure why meds are being pre-poured for use while at the facility.

[roser13, ASN, RN]

Are you a student? If not, why are they threatening to tell your school?

[Whispera, MSN, RN]

If you're a student why are you dispensing medications? Is your teacher there or do you have a preceptor on the night shift? One or the other is required.

The nurse who gave the medications is more at fault than you. One should NEVER ever give meds someone else dispenses to a container.

[mcleanl]

I suspect the OP is referring to the "college of nurses." It is a equivalent to the US's BON.

[jenna84]

Yes I meant college of nurses. Not the nursing school...

[PacoUSA, BSN, RN]

Yes I meant college of nurses. Not the nursing school...

Perhaps this is the equivalent to "state board of nursing" in the USA? From the way the OP spelled "centre" I have to assume she is outside this country.

[Been there,done that, ASN, RN]

Sounds like they are making You do pharmacy's job.... along with all your other duties... and threaten you when you make a mistake. We are NOT allowed to dispense.

Talk to a lawyer.

[punkydoodlesRN, BSN, RN]

Where I work, I pull the next shift's meds, and mine are pulled as well... BUT BUT BUT!! They stay in their blister packs AND I still do my 3 checks before giving them.

What the OP describes sounds very dangerous.

[Pepper The Cat, BSN, RN]

i don't think you have much to worry about.

if you are reported to the college of nurses, just tell the truth, say what you've learned, what you would do differently. the college isn't looking to punish people who have made honest mistakes, which is what you have done.

to those of you quesitioning what the cno is - it stands for the college of nurses of ontario and is our regulartory board - similar to your bon. though they are called a college, they are not related in any way shape or form to an education institute.

from the cno website:

the college of nurses of ontario is the governing body for registered nurses (rns), registered practical nurses (rpns) and nurse practitioners (nps) in ontario, canada.

the nursing profession has been self-regulating in ontario since 1963. self-regulation is a privilege granted to those professions that have shown they can put the interests of the public ahead of their own professional interests. it recognizes that ontario’s nurses have the knowledge and expertise to regulate themselves as individual practitioners and to regulate their profession through the college.

the college fulfils its role by:

• establishing requirements for entry to practice
  
• articulating and promoting practice standards
  
• administering its quality assurance program
  
• enforcing standards of practice and conduct
  

the college also supports the regulation of nursing in the public interest by:

• participating in the legislative process
  
• sharing statistical information about ontario’s nurses
  

the college works in partnership with employers, educators and government so that everyone in ontario benefits from quality nursing services.