Nervous over possible termination

[funsizedliv]

So I haven't posted in a long time. Since my first thread, I have graduated, worked in a crappy job for 6 months, and since leaving there, I have been at a facility for one year this week. So this is what I am worried about:

I found out that I had made a med error five days in a row, ( I didnt check the dosage listed on the pill card). I was taken of the schedule for sat, and sun., and asked to meet with the DON on mon(holiday). She was not in on monday (my normal day off). I arrived to work on tuesday and was not on the schedule. I am terrified that I am going to get fired, is that likely?

backstory: I work on an acute rehab floor. We had been pretty empty for a few months, but there suddenly was a surge of admissions which really threw us off. Many having some pretty serious issues, one even being returned to the hospital for elevated potassium that the hospital missed (he seemed the most healthy out of all of my pts). Several of my patients require A LOT of nursing care, I have two MR patients, one is non-verbal and has bolus GT feeds, I have one psychotic patient on dialysis who is 90 years old and not doing well, yet refuses to sign a DNR, I have a woman with expressive aphasia who now has a GI bleed, A pt with hepatitis B+C with 4x daily blood sugars and behavioral issues, a 80yr old new gt patient with recurrant aspiration pneumonia running a temp of at least 100.0 for 3 days, and lastly, one with PTSD and severe anxiety who, despite 'wishing she were dead' for needing one, requests an enema every morning, and those are just the heavy ones.

For my end of the unit, I am one nurse to 18pts, I have two CNA's ( who arent allowed to do much more than AM care and toileting per the facility). I am responsible for all treatments, meds, and skilled notes on 17/18 of them. There is a charge nurse (who I consider my mentor) who has every intention of helping, but she is so bogged down with orders that she cant get away from the desk.

We also have a new MD and a team of NP's that work with him. One NP comes in daily to take off some workload from the MD. This new doctor has most of the patients on the unit, approx 30pts. For some reason, they stopped giving the other two MD's (one being the medical director for the floor, the other is the former director) admissions. Well once this NP came in, instead of checking patients and ordering things, she began overhauling how we do things. She even hijacked our part-time unit clerk, keeping her on the floor at all times (and now she has no time to do medical supplies, her primary job).

So this made a mess of everything and caused confusion for the staff. We finnally started getting the hang of it though after a few days. So she wants: VS and weights as soon as she arrives on the floor. (of course this is done before meds anyway, but my cna's havent done vitals at this facility, and its like pulling teeth to get weights done.) So When I arrive on the floor in the morning I (personally) have to: take VS on all 18 patients, make sure weights are done before breakfast (the 11-7 shift wont do them) get report, count, check the breakfast trays and help pass them out, check the bm book, check the apointment book, then I can start my med pass. Then, once the NP arrives, she tears through things, bombarding us with questions that I usually dont have the answer to, then gets really annoyed with us and 'throws us under the bus' to the DON. Then I can finish the rest of my work, but I havent been able to get done on time for a few weeks now.

I have so much to do and so little time (I have never taken a lunch break since I started BTW), that I have to rush through everything, and having ADD, I already dont have a good attention to detail all the time. (not to mention it is really hot on the floor, I sometimes think they are doing a study on our behaviors related to intense temps.)

On thursday we had staff meetings, the State had just done our survey, and then returned to investigate problems they found. After the meeting I attended, the DON asked me and the charge nurse to stay behind. She told us what needs to change on our floor and that we are not up to her standards of quality at that time. She even told us to change our handwriting becaus its 'too loopy'. She said she was trying to motivate and not push people out of the facility. (she told me that I was going to be the death of her).

So later that day It was discovered that I had been giving a patient too much digoxin for five days. He was supposed to get 0.125mg but was getting 0.25mg. I checked his AP before each dose and held it on the day that the error was discoverd since his AP was 55. The NP was looking at his labs and discovered he was in dig toxicity, she asked my nurse manager to investigate. When my manager asked about the med, it clicked. I knew that the dose ordered was 0.125mg, but the med I had was 0.25mg, I had been rushing through the meds and I never got to check the dosage on the pill card. (the pharmacy also never sent the correct card, and the old one was never removed from the cart). So I felt terrible, cried my eyes out once I was home, and was worried sick about the patient. (I found out this morning that everything is ok and he is out of toxicity). It was all my fault, I am the primary nurse and missed this error for days. (there was only one other nurse who gave him the med on the weekend, but I dont know if anything happened with her).

So on friday (my day off) I was very nervous to return to work on the weekend, expecting the worst for the patient. But at 7:30pm on Friday, I get a call from a coworker (turns out to be the nurse who trained me a year ago), telling me that the DON called her from home, and decided to take me off of the schedule for the weekend, and wanted to meet with me on monday. (monday being a holiday and my normal day off). So before ending the conversation, the nurse passing on the message wished me a 'good little vacation'. I didnt know if she knew what had happened on thursday so I just shrugged it off. So now, again with the waterworks. Fearing that I will be fired

I prepared for my meeting with the DON. I listed what I need to improve on, where I need help, and problems on my work floor that directly affect my work. I also posted my resume online and applied for jobs just in case.

Monday comes, I call work and leave a message for the DON to call me when she wants to meet up. (it was a holiday so she didnt come into work that day, as I expected. ) So, no call back on monday.

Tuesday (today) arrives. I get ready for work and prepare myself again for my meeting with the DON. I get there, and my name is off the schedule. The DON is not in yet, but I happen to bump into my floor manager. I tell her about the weekend (she seemed blank expressioned so I couldnt read if she knew something or not). I asked about the patient, and she informed me that he was fine, back to baseline and the med was d/c'd. So I asked her to have the DON call me when she see's her so I can meet with her. That was at 7am (its now 8:42a).

I am hoping that I was given the weekend off because the DON recognized that I was overworked and that led to the med error, but I fear the worst, and that I will be out of a job. (they reciently have 'cleaned house' and escorted staff out of the building, the charge nurse I work with thinks she and I will be next)

Any thoughts are appreciated.

[BelleKat, BSN, RN]

"turn and burn nursing"

An excellent description of today's nursing unfortunately.

[cyadontwannabeya]

Man sounds like that place needs to be investigated by DHS. One thing is for sure you are only human and can only do so much in one shift. You do not sound like a slacker but your peers sure do. I would get the hell out of there as fast as I could.

[EwwThat'sNasty]

There are a number of worrisome aspects to your note.

You say that you "knew that the dosage was 0.125" milligram, but that you had 0.25 milligram. Then you say you "never got to check the dosage on the pill card." Adding the "pharmacy also never sent the correct card, and the old one was never removed from the cart."

You don't tell us the age of the patient, though I wonder if it was the "psychotic" one, for dig toxicity can induce psychotic behavior. If the patient was elderly you should know enough about digoxin to realize that 0.25 milligram, especially for an elderly patient is a high dose. Were you watching for symptoms of dig toxicity?

Habit can be a factor in med errors. Our minds can run automatically, thus the five rights. Med errors kill people, though moderate digoxin toxicity (as far as I know) usually doesn't, but it doesn't help them and can make life miserable. Five rights, every time bypasses the brain on automatic, which is why we do it.

So for five days you ignored "right dose." I'm sorry, but this is inexcusable. ADD is no excuse either. If you are ADD and methylphenidate does not allow you to focus you cannot do this sort of nursing. If you do as much as you do, and get it done, then for you ADD is not likely a problem. If you have ADD then the five rights are even more important for you, for then your mind will automatically do the correct thing.

That you are overworked seems obvious. That you are at risk seems obvious. That your facility has problems is obvious. Clearly this work is not your kind of work (sometimes I wonder if anyone can do this sort of thing that one finds again and again in many small facilities). Why not consider something more linear? Visiting nurse, hospice, public nursing...the list is endless. Some like public nursing (public health, immunization programs, state STI programs, etc. will pay less. But you will probably live longer.

Don't feel bad if you're not suited for this type of job. I'm not. (been there, done that) I suggest that if you are lucky enough that you don't get fired for this I suggest trying to get a bit of distance from the problem then give proper notice and find something else.

[leslie :-D]

i'm sorry, but repeating the same med error x 5, is worrisome...

regardless of the workplace and all of its atrocities.

i would much rather give 10 of my pts, the right meds, than give 1 pt (out of 18) the wrong one.

in other words, do not let others push you.

take the time to ensure the 5 rights of med admin.

i made a very costly med error many yrs ago, and will NEVER allow myself to feel so stressed, that i cause serious harm to a pt.

from what i hear, this is a typical case load for subacute/rehab.

yes, it's deplorable.

but you are in control and are the only one who can make safe decisions.

as you know by now, no one else has your back.

when it comes to nsg, only we can protect ourselves, and that often entails JUST SAYING NO.

be good to yourself.

and take it one patient at a time.

your pts as well as yourself, deserve the very best,.

leslie

[LilyBlue]

Run like the wind; this job is not safe and your license is in jeopardy. Also, consider this a lesson regarding "med cards": Check your original orders. Check twice. My first nursing job used "med cards" besides the MAR and the other nurses couldn't believe that I didn't want to use them. They were just another opportunity to transrcibe an error was my thought.

You haven't had this job long, so no need to mention it on future applications. Just something to think about.

[Vito Andolini]

Well, just a couple of thoughts. First, had you been fired, it would have been a blessing. The place sounds impossible.

If the Alzheimer's ward is as bad as the other one, just go find other work.

That NP needs to be put in line. Not by you, though. Just she needs to know she can't commandeer the ward secretary, she can get her own VS and she can make noises to get the night shift to do the weights. That's who should be doing them. Be glad you're gone. You're lucky the med error patient is alright.

I hope things work out well for you. You sound like a hard worker but, frankly, foolish. You are letting them walk all over you and you are going to be the one who ends up sued. You've already let the impossible job load cause you to pass meds incorrectly and give up your necessary breaks, donate your own time to the job, and try to do the impossible task of trying to please that NP. Time to get real, realize your limitations, and start protecting yourself.

Take your breaks. Make med safety a top priority. The NP's wishes for VS and wts are important but not nearly as important as you keeping your license by passing meds correctly. Don't discuss anything with her or anyone else, don't try to explain, justify, or convince. Just do what you need to do to be safe.

[LHH1996]

It sounds like your DON could be helping out alittle more!!!!!!!!

[NotFlo]

I agree with everyone who says you should do the five checks, etc.

But the truth is in this environment (LTC/subacute) these types of errors happen all the time.

When I first started my current job I was passing meds with a preceptor and found that a patient was formerly getting a short-acting version of a drug QID. The order had been changed to a long-acting version once daily. The pharmacy sent the long-acting version but for at least a week every nurse that worked days (there were at least three) had given the long acting drug QID. Finding that error explained a lot of the issues the patient had been having the past week. He was fine, thankfully.

I don't pat myself on the back for this one though, probably the only reason I even noticed it was because it was new and I was a fresh set of eyes and I was *really* doing my three checks and five rights and concentrating very hard becuse I didn't know any of the patients.

I also float in my current job, and I notice for the nurses that don't float, things become routine, and every single word of every single order in the MAR is not read every single day. I have had many times where there's a new order for a drug, say K+, the dose may be 40 meq, pharm sends 10 meq capsules, and a week later on a card of thirty there are only seven caps. gone.

Also stuff like an order is changed, say Paxil increased from 10mg to 20mg, old card is left in the cart and pt. continues getting 10mg for a week. Obviously, there could be more consequences to this depending on the drug involved. That's why I always pull the med card right out when an order is changed. We have stickers that go over the orders on the card that say "order changed, refer to MAR" but even that doesn't give some people pause...I think some people don't look at the med card at all, honestly.

Anyway, don't beat yourself up. It sounds like things are a mess on that floor. The pt. load is normal for subactue, but they really need to get the CNAs doing AM vitals and reorganize things to make it possible for the nurse to do her job. When the state's there they want to see you pass your meds in the proper time frame, they don't want to see a nurse running around doing a million disparate things during the med pass.

[SuesquatchRN, BSN, RN]

so, I just had my meeting. those days I had off will count as suspension without pay. then tomorrow I have to redo orientation with the staff educator. then they are transferring me to the alzheimers unit. they think that since my current floor is so crazy right now and since I'm a fairly new nurse, the alzheimers unit will be good to help me learn assessment at a slower pace. I actually started out on an alzheimers unit when I graduated. but I dont know if i will be staying at this facility.

*phew*

And find another job.

Good luck.

[NotFlo]

Oh and I'm afraid at the Alz. unit you'll have 30 or more patients and an unbelievably long med pass. That's how it is here, unfortunately!

[TigerGalLE, BSN, RN]

Wow... I feel so stressed for you. I know this is an "acute rehab" floor. But it sounds like you have some very sick patients. I think some people on here are being too hard on you. Yes making a med error 5 days in a row isn't a good thing... But how on earth can anyone expect you to get vitals and wts on 18pts, do 18 assessment, pass morning meds, chart, check new orders ect ect.... This would probably take me all day!!!!!!!!

I really think you need to find a different job. This place sounds like my worst nightmare!! I think I've had nightmares like that before. This place is unsafe and your workload is too much! Start looking for a new job today and put in your 2 wk notice tomorrow! I'm so sorry you have to go through this.

>>>

Tiger

[123angiecat]

Wow, what an awful experience for you:)

It is the same old story--management focusing in on an error and not on the real issues---one RN for 18 patients in acute rehab. How crazy is that??

I am glad that you are getting off that unit!

Management should be thinking about how their staffing levels and expectations are affecting patient care. Patients are not going to get the kind of care they need and they are going to get eventually get sued by someone.

I have been a nurse for a while now and I wouldn't have lasted as long as you---I would have been out the door after the first week.

As the nursing shortage isn't going to get any better, there are lots of jobs out there and places where you will find better working conditions.

You go girl!!!:)

All the best:)