Need Advice on Accused Medication Error

Shannon Dull Dunlevy · Dec 1, 2019

Exactly! I try yo do what I'm supposed to and lay low. There is no way that I skated through the entire semester without a hint of trouble and then on my last day I get written up for three things! One of those things was wearing my engagement ring on my right hand. We aren't supposed to wear any jewelry that isn't a marriage ring. My fiance died so I switched it to my right hand. It's hard for me to not be headstrong. I'm learning LOL.

beachbabe86 · Dec 1, 2019

6 minutes ago, Shannon Dull Dunlevy said:
We aren't supposed to wear any jewelry that isn't a marriage ring. My fiance died so I switched it to my right hand. It's hard for me to not be headstrong. I'm learning LOL.

I am so sorry to hear this.

I get the feeling you are going to be a great nurse!

chare · Dec 1, 2019

28 minutes ago, Shannon Dull Dunlevy said:
...It's hard for me to not be headstrong....

This is something that you are going to have to learn to control. It's placed you in the spotlight and going to create problems for you now, as well as later after you graduate.

Best wishes

Shannon Dull Dunlevy · Dec 1, 2019

8 minutes ago, chare said:
This is something that you are going to have to learn to control. It's placed you in the spotlight and going to create problems for you now, as well as later after you graduate.
Best wishes

Well, my plan is to go into medical law once I graduate. Could help there lol.

VNurse30 · Dec 2, 2019

How would you know whether or not someone had rinsed it out after the med administration? That could've been water there for all you knew.

That being said, I feel for you.

Correct me if I'm wrong but you may have been too verbal about someone turning off the machine. Loose lips sink ships sometimes. It's best to keep quiet and observe and not talk about how things "should" be done. You never know if you'll be stepping on toes you shouldn't be stepping on.

My defense would be that I didn't realize that I should have turned it back on, and I would tell them that I have definitely learned from situation and that it wouldn't happen again. Then I would listen to what they say. But I'd want the entire situation documented on paper and I'd get a copy.

VNurse30 · Dec 2, 2019

On 11/27/2019 at 5:32 PM, Shannon Dull Dunlevy said:
I was not allowed to bring an attorney or anybody on my side to advise me during their questioning. I did have a few instances throughout the semester with this particular professor. Minor things that I did point out because I thought she handled the situation completely wrong and she didn't like that. For example, one of my patients was combative and A&O x's 1. I spent about 15 minutes trying to get a pulse ox while the patient (who was 100 years old) kicked, scratched, punched and bit me. At that point I decided that getting a pulse ox at that time was not a good idea. The patient was on room air and very feisty and calling me names. I reported back to my instructor and she told me if I was a real nurse that I would be fired for not being able to obtain a pulse ox. I basically told her that I was not fighting was somebody who was a hundred years old and the patient was becoming more combative and it wasn't in the patient's best interest and that instead I felt the best way to determine the patient's respiratory status was by observation until the patient calmed down.

OK, I read the update and I'm getting more back story. Ask for help instead of saying that you can't do something. And never challenge your instructors like this. Especially over a non life or death situation.

**NICU Guy, BSN, RN** · Dec 2, 2019

On 11/27/2019 at 5:12 PM, Shannon Dull Dunlevy said:
At that point the error technically fell on her, but then they started grasping at straws to make it somehow be my fault. In the end it was determined that it was my fault because I failed up finding out who took it off the patient in the first place.

On 11/27/2019 at 5:32 PM, Shannon Dull Dunlevy said:
I reported back to my instructor and she told me if I was a real nurse that I would be fired for not being able to obtain a pulse ox.

Unfortunately, schools sometimes hire clinical instructors that shouldn't be teaching students. Hopefully, the school learned their lesson and that instructor will not be hired back for the next semester. The school knew that you were in the right, but they needed to save face by finding something to blame you for. They couldn't punish you for leaving the room when your instructor told you to leave the room, so they dropped it and let you continue on to the next semester.

As others have said, keep your head down and avoid the mine fields, if possible.

Shannon Dull Dunlevy · Dec 2, 2019

8 hours ago, VNurse30 said:
OK, I read the update and I'm getting more back story. Ask for help instead of saying that you can't do something. And never challenge your instructors like this. Especially over a non life or death situation.

This was a different patient. There were 4 of us trying to "help". The facility nurse (the patient's nurse) told me to stop, and document as refusal and try again when the patient was calm. So....that's what I did, and it worked.

Kooky Korky, BSN, RN · Dec 4, 2019

On 11/27/2019 at 12:23 PM, Shannon Dull Dunlevy said:
. At the end of the day I still get to move on to the next semester.

And that is all that matters. You did not screw up, it was your stupid Instructor who did.

And you took the unfair punishment and you get to move on. That is what really matters at this point.

I am glad you sucked up the unfairness heaped upon you. you will long remember this. Someday, long in the future, you will perhaps hear that this stupid Instructor and those who backed her up have suffered some unfairness.

Move on for now. Best wishes.

Kooky Korky, BSN, RN · Dec 4, 2019

On 11/27/2019 at 4:12 PM, Shannon Dull Dunlevy said:
My instructor found out it was an aide that had taken it off. She did not disclose that information with me until the meeting. The head of nursing stated that we were in fact to stay with the pt during treatment and asked why I did not. I stated "because Professor so and so told me to come with her to document the treatement". At that point the error technically fell on her, but then they started grasping at straws to make it somehow be my fault. In the end it was determined that it was my fault because I failed up finding out who took it off the patient in the first place. However, if I had been there for the whole treatment like I should have been none of this would have ever happened.

bunch of self-protecting hypocrites;

May they slip on a bunch of monkey doo. And there be n scrubs to change into.

melissamabd, DNP, RN · Dec 4, 2019

Hi-- my research is about medication errors. I am not convinced this was an error; and actually, nursing needs to change its culture. We are not perfect, never will be, just as we're not perfect in other areas of life. The edict that we should be perfect is abusive/in my opinion a woman's issue.

Anyway, I wanted to express my support. You are a second victim of this incident- it's traumatizing you. As a seasoned instructor, I would use this as a teaching moment and discuss the critical thinking needed to make that decision. It sounds like you did the right thing by going to your instructor... and that someone sabotaged you, a form of horizontal violence.

If you need more support, reach out to me at [email protected]

Melissa Davis DNP RN

thenewspirit · Dec 4, 2019

On 11/23/2019 at 6:19 PM, Shannon Dull Dunlevy said:
So, here is the situation. I started a DuoNeb treatment on my patient WITH my professor/instructor. Once the treatment was started we left the room and documented the treatment. I checked in on patient about 7 minutes and and everything was fine. At around 15 minutes I checked on the patient and noticed that someone had taken the face mask off the patient and turned the nebulizer machine off. When my instructor came back I reported that someone had turned the machine off. My instructor went into the room alone and reported to me that she had re-initiated treatment because there was still some DuoNeb in the reservoir. I was written up as having made a medical error because I did not personally take it upon myself to start the treatment again. My rationale behind not starting the treatment by myself is:
I wasn't sure who stopped the treatment in the first place. It could have been my instructor for all I knew.
I wasn't sure WHY the treatment was stopped. The patient may have been observed having adverse reactions for all I knew.
I do not feel that I as a student, working under another's license, should make the clinical judgement to restart the treatment on my own accord.
What do you all think is the best move here. I have a remediation meeting in a couple days.
I feel like the persons who made the medication error was #1, the person prematurely stopped the treatment and didn't document or notify anyone, and #2, my instructor who restarted treatment without knowing who stopped it in the first place and why.
Thanks

Communication is a top cause of medication errors and you have just illustrated this in practice.

Your professor is not trying to write you up to mess with you.

Swallow your pride, listen to your instructor and if you cant learn from being written up for something that is not completely 100% true - look for a different job.

What you should have done is stayed with the patient from the beginning to the end of the Duoneb. Once you left and came back, someone could have washed/flushed out the nebulizer mask and the remaining "medication" you saw inside was left over. Someone could have spit inside the nebulizer chamber for all you know. Who turned off the mask? Maybe another patient. Maybe the cleaning person. Probably it was an aide. If you can learn from this and understand the dynamics of workplace groups.