co-worker fired due to me - page 2

have you ever heard of anything like this? Monday I had to complete an incident report due to a med error. The error occured the eve before when me and my coworker were working intermediate ICU with... Read More

  1. by   Nurseprotect
    I will begin by quoting the book "Medication Errors...Causes, Prevention, and Risk Management" written by Michael R. Cohen, MS, FASHP President of the Institute for Safe Medication Practices in Huntingdon Valley, Pennsylvania
    "It is often convenient for managers, patients, and families who are trying to come to terms with an incident to blame the practitioner. Althought this reaction is UNIVERSAL, NATURAL, EMOTIONALLY SATISFYING, AND LEGALLY AND POLITICALLY CONVENIENT, it has little or no remedial value. This is because it focuses on the last and probably the least remediable link in the accident chain, which in most cases is the direct care provider...the purpose of investigating errors should be to determine what system elements, such as poor labeling or packaging, or short staffing, or long hours, were contributing factors...The emotional and spiritual distress that follow the error may be very overwhelming...Most health care professionals who have erred require reaffirmation of their professional competence and, in many cases, reassurance of their personal self-worth."

    Please call the Institutes for Safe Medication Practices at (215) 947-7797 and ask them how to proceed-they are the experts on this subject-nobody can argue effectively with their recommendations.
    One of my main questions is why does your unit stock more than one concentration of Heparin on the unit? This is a drug with high potential for error. There are obvious system problems. Fight for the rights of your colleague-she is probably feeling like she has no basis to defend herself. You can report the Chief Nurse Executive and/or Nurse Manager of the unit to the Board of Nursing for failing to maintain a safe environment for patients and nurses. You will probably get fired and maybe even blackballed for this so be forewarned-and legal battles are not easy to win even with these "protections" in existence for whistleblowers. This could have been YOU or ME very easily-something nurses should never forget. If you told me that this was her third med error to my face I would give you a look like "what's your point?" If you look at the definition of what constitutes a med error you would see that they are made all the time. It is the "perfect" nurse who never makes mistakes that I fear most.
    This act of advocacy that you have initiated by posting this to the group is highly commendable-we need more like you in the profession. Please keep me updated on this forum or privately at
    Let me know if you need more referrals or information. Med Errors are a hot issue with Board of Nursing regulatory issues and I have compiled a considerable file on the subject to use in defense of nurses.
    Steve Lee, RN
    Phoenix, Arizona

    Originally posted by minurse:
    have you ever heard of anything like this? Monday I had to complete an incident report due to a med error. The error occured the eve before when me and my coworker were working intermediate ICU with a 12/2 ratio--4above standard-- and my coworker hung the wrong concentration or Heparin for a drip. The incident was written as unsafe staffing led to the error. WELL... apparently this is my coworkers 3rd incident report (in her career) for a med error and she will be fired!!!! I think this is crazy and need to hear from nurses that have experienced something like this.
  2. by   PPL
    I would just like to thank Mr. Lee/Nurse Protect for his work in defense of nurses. It's good to know that you're there; as any one of us could be hung for a simple, honest mistake. THANKS!
  3. by   pickledpepperRN
    The JCAHO and Institute of Medicine recommendations are to search for "Root Cause Analysis" that focuses on systems NOT blame.
    I commend you for advocating for your fellow nurse. The IOM report is called "To Err Is Human"

  4. by   NurseRachet
    We have a system in place for reporting medication errors that is non-judgmental and doesn't count "numbers of errors per nurse". We also do a "root analysis" of a medication error of a potential or dangerous reaction. I was more concerned about the nurse atient ratio - that is way too many patients for one nurse. Not sure where you are, but I wouldn't want to work there. Your hospital is at blame! I would also seek legal counsel. The nurse reporting the error is not at fault - the primary nurse and the institution is at fault. Good luck.
  5. by   mustangsheba

    Minurse: I know how awful you feel! It happens when we look for someone to blame instead of looking for the solution to it's not happening again. I can't add anything to what everyone else has posted. Just wanted to add a little support. When I was a new nurse 20 years ago, I was asked to work the night shift following my evening shift. The next morning, I removed a urinary catheter from a woman who had an MMK. It took me less than 5 minutes to go get a hat to measure her urine, but when I returned, she had already gone to the bathroom and voided. The doctor was waiting at the door pointing to his order. The date was for the next day. I was so tired, it took me a while to realize what day it was. He told me to do an incident report, which I did. I later found out he told the supervisor that he had seen me all evening the day before and then when he arrived that morning, and that I would never have made the error if I hadn't been exhausted. His advocacy didn't make any difference in our staffing, but I've never forgotten the lessons: 1. Doctors' actions are not always punitive, and 2. When tired or stressed, double check all those orders. Your coworker should not leave because of this incident, unless it is the impetus for her to start in a new direction that she needed to do anyway. MS

  6. by   ratchit
    I agree with the other posters about the unreasonable treatment of your coworker. But your subject line isn't fair to yourself- you filed an incident report on a med error- required under every nurse practice act and hospital policy I have ever been subject to.

    The staffing of the unit is certainly a concern and please do get legal counsel before this meeting with administration- that documentary about 90,000+ deaths a year from hospital errors was too recent to dismiss!!

    The incident report itself didn't cause the problem- your coworker should actually have filled it out herself.

    Good luck.
  7. by   goldilocksrn
    Of course management and administration won't acknowledge staffing shortages as an issue because then it would have to be fixed. The nurse is easy to blame. I agree with the other posters when I say that if you know the staffing is unsafe, then refuse the assignment, stir up some trouble. If you don't, you will be to blame (this story is a case in point) I almost discharged a patient today that wasn't supposed to go home until tomorrow (MD had written out instructions and prescriptions, and in a tiny corner wrote tomorrows date as DC date) Our supervisors were hot and heavy on the phone to push people out the door because people with Chest pain were sitting in chairs in ER. OUR MOST BUSY AND STRESSFUL TIMES ARE WHEN FATEFUL ERRORS TAKE PLACE. THEY CAN ONLY PUSH AS FAR AS ER LET THEM!!!
  8. by   -jt
    ...Minurse: I know how awful you feel....I would never have made the error if I hadn't been exhausted. His advocacy didn't make any difference in our staffing...

    I have no patience for these kinds of things. We have to advocate for ourselves & in these times its going to take a lot more than "talking". Min, You are to be commended for working so hard & being so prepared to present your case. But unless you have the legal backing of being unionized, the hospital does not have to listen or act based on your evidence & nothing can force them to. Nothing is ever going to change until nurses change it. The hospital has all the power & can do anything they want even if its as unfair as blaming the RN for failing in a system administration has set up to fail, unless you demand the right to share that power as an equal partner & make it legally binding. How much more are nurses going to put up with? Nurses complain & complain & give horror stories & tales of injustices against them yet the one thing that will stop this is something many of them wont even consider. I will never understand how people would rather live in these situations from facility to facility and state to state & not exercise their federal right to have a say what is being done to them. You can talk till youre blue in the face & it wont change a thing....until you talk with one loud COLLECTIVE voice - that is upheld by the law.
    Organize with an RN association & unionize yourselves against these continued abuses.
    What are you all waiting for???????

    "Feel the Fear - do it anyway."
    -susan jeffries