medication error


As an agency nurse I made a medication error I did'nt realise a pain killer patch was a controlled drug. When I did'nt find the prescribed patch with the patients normal meds I looked in a cupboard which held additional medications that was not stored in there own individual cupboard. I failed to realise there was another cupboard which stored controlled drugs. I documented the drug as unavailable on 2 occasions. A month later I was challenged on this by the home manager who told me she had been inspected and the error was highlighted and she had been scored down for this. I was devastated and informed my agency as the home did the day after. I was then suspended and asked to completed a reflection and medication questionnaire. I am still awaiting outcome but have not worked since. The error was made whilst working in a dementia home I am used to working with mental health conditions such as schizophrenia. I am so disappointed with myself and I am de sated I might have caused this old person more misery than they should have. Does anybody know if this will mean me loosing my pin. I have never made an error before and have always been praised on my practice.

Has 13 years experience.

I'm not sure what medical training you have had. Most "pain killers" are controlled substances. There are a few like acetaminophen & ibuprofen that are not. Perhaps you need to review the medications you are providing to patients.

Has 33 years experience.

I don't quite understand what cupboard you are talking about, most narcotics even patches are kept in a locked drawer or cabinet that is locked. The narcotics have to be counted every shift, so the error should have been found when the narcotics were counted after your shift. Technically, it was a medication error, as long as the patient did not suffer any consequences I do not believe it should affect your license. Your agency has suspended you, so that will be on your personal file.


392 Posts

Specializes in Oncology, Rehab, Public Health, Med Surg.

Not all pain patches are controlled substances. Lidocaine patches for example


4 Articles; 10,428 Posts

Not all pain patches are controlled substances. Lidocaine patches for example

A nurse would be expected to know that Lidocaine patches are not controlled substances, but Fentanyl ones are. I'm curious how it is the OP didn't know narcotic patches are controlled substances?

Also, Gilffy: you are concerned about "losing your pin". I would think losing your license to practice nursing in the US would be of greater concern....? What IS your license: RN? LPN?

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Silverdragon102, BSN

1 Article; 39,477 Posts

Specializes in Medical and general practice now LTC. Has 35 years experience.

As they are talking about PIN I suspect they are in the UK. Narcotics should still be counted and I suspect you just take this as a learning curve. I seriously doubt you have done something serious enough to warrant the NMC removing your license