honest mistake and treated like a criminal

  1. Hello all. I'm new here. I'm looking for an unbias opinion/support for my situation. I am an LpN and will be graduating with my BSN in a little over a year. This is my first nursing job and I've been here for three months. Recently I switched from 11-7 to 3-11..very overhwelming to say the least. Okay here goes.. I was passing meds. I accidentally spilled two cups on my med cart and some od thr floor..I sorted them out and threw out the ones that fell on the floor and repoured what I needed to.. and went on to administer the meds to the patients. One of the pills was a narcotic. The patients didn't say anything about the meds and neither did the other nurse that was in the room. I went on about my night. Next thing I know I'm getting pulled into the supervisors office saying I gave a Tylenol instead of the narcotic ..honest mistake since the pills are almost identical in shape and size. I was in a hurry and I admit I should have checked better to make sure I was giving the right pill to the right person. Thankfully no one had an allergy and no harm done. I was treated like a criminal and I had to take a drug test. Now I am waiting for the results to come back and I've had two meetings with the DON. She is saying it sounds suspicious. I'm so frustrated. The kicker is that I take pain medicine prescribed by a doctor for over ten years and so they are looking at me like I did this on purpose. I'm thinking I'm going to lose my job over this incident and I just want support and to see if this ever happened to anyone else. I'm a really good nurse ..ive been told so by many of my patients.. And on top of it the patient that this happened to is totally with it so why would I deliberately take his when I know I could get into trouble?? I have access to thousands of narcotics and people who can't speak... and I've never had a complaint before for any narcotics going missing.. Any advice would be greatly appreciated.
  2. Visit pretty_LPN profile page

    About pretty_LPN

    Joined: Sep '14; Posts: 6; Likes: 1
    LPN; from US
    Specialty: 1 year(s) of experience

    18 Comments

  3. by   Karou
    I don't have much to say except in the future you should discard/waste all the pills if any are spilled and redraw all of them again. That way you actually know you are giving the patient all their prescribed medication. Too many pills look alike.

    Hydrocodone does look like Tylenol from a distance but at close it's easy to tell the difference.

    Sorry you are being investigated for this accident, however it was a med error and you could have acted differently to prevent it. Lesson learned. Just know that your supervisors are doing what's required on their end after such a med error.
  4. by   poppycat
    If you have malpractice insurance, you should contact them for an attorney. Depending on what the facility investigation finds, they could report this to the BON.
  5. by   pretty_LPN
    I've been thinking that also but the facility covers us for malpractice if I'm not mistaken.
  6. by   pretty_LPN
    What immediately came to your mind when reading this?
  7. by   poppycat
    The facility's malpractice insurance covers THEM. If they find something they think you are guilty of, their insurance won't help you. This is why every nurse should have his/her own malpractice insurance. You need someone who only has your interest in mind.
  8. by   poppycat
    What came to my mind is that they may very well report this to the BON.

    Just out of curiosity: did they do a drug test when is occurred?
    Last edit by poppycat on Sep 26, '14
  9. by   Anna S, RN
    This is not malpractice- it's a med error. The OP's employer appears to suspect her of diversion. Malpractice insurance has nothing to do with that. If you are not immediately cleared, you might consider getting a lawyer to protect your rights/advise you.

    If they did a drug test because this occurred, then it wouldn't be random.
  10. by   loriangel14
    Quote from pretty_LPN
    What immediately came to your mind when reading this?
    First off, why did you have two cups of meds poured at the same time? I would have repoured them all or been VERY careful about sorting them out.
    I'm sorry you are going through this.It sounds like an honest mistake.
  11. by   poppycat
    Quote from Anna S, RN
    This is not malpractice- it's a med error. The OP's employer appears to suspect her of diversion. Malpractice insurance has nothing to do with that. If you are not immediately cleared, you might consider getting a lawyer to protect your rights/advise you.

    If they did a drug test because this occurred, then it wouldn't be random.
    First off, I never said it was malpractice. Malpractice insurance policies provide attorney coverage for situations like this. If she's reported to the BON she will need to have an attorney. Second, if you were going to jump down my throat, why did you "like" my comment?
  12. by   annie.rn
    Quote from pretty_LPN
    What immediately came to your mind when reading this?
    This is what came to my mind:

    "Oh, no!"

    As some previous posters have pointed out, I think it would have been better to start over from scratch w/ pouring the meds...especially since there was a narcotic involved. I would have asked the nurse in the room to act as a witness to what happened and have her watch me throw out the narcotic on the spot. (I like to have someone watch me dispose of a wasted narcotic tablet into the sharps container so there is absolutely no way anyone could say it was diverted) I know that is a huge time suck when you have a busy med pass but you can never be too cautious. Once the pills are out of the package you can no longer check all the "rights" of administration.

    In the future: don't pour two sets of meds at the same time ever again. It really is unsafe practice. I can kinda see how the nurse that saw it would be a little surprised. It must have looked pretty bad to her watching you sort through all the spilled meds, trying to figure out whose was whose. Also, I feel it's better practice to pull the meds one by one, place them on the pt.'s bedside table so that they can see them and then open them up one at a time while telling them what each med is as you are unwrapping them. Then, it's much less likely a pt. can say you gave them a Tylenol vs. a narcotic.

    That being said, the nurse that was witnessing this should have stopped you when it was happening and offer you advice and assistance instead of running to your supervisor and telling on you. Especially since this was a pt. safety issue. He/she was obviously concerned a pt. could get the wrong meds so why would he/she stand there and let it happen (not that we know for sure it did but I am assuming worse case scenario).

    As far as the drug screen, I think the fact that you already take pain medication (especially if it shows up the same as the narcotic you were giving) may be problematic if they want to be sticklers about it. They could say that there is no way to tell whether you took your prescribed med or a diverted pain med.

    I, too, feel like this should be a med error/teaching moment but it seems as if they want to make things very difficult for you.

    Don't know if it's possible to get malpractice insurance this late in the game but I would be on the phone w/ a malpractice ins. agency at opening of business today to find out. I would buy a policy regardless.

    If they escalate this to your BON you will need the help of a lawyer.

    So sorry you are going through this. {Hugs}
  13. by   poppycat
    I would also be getting a malpractice insurance policy ASAP even though it won't help with this situation.
  14. by   TiffanyRoseRN
    Wait something just doesn't make sense... If both a Tylenol and What ever pain medication dropped on the floor... And the patient got Tylenol instead of let's just say oxycodone (don't really know any pill that looks like a Tylenol). Who got the oxycodone? Is it still on floor? Another patient? I think that is where it looks suspicious? Also you say you have been there 3 months so you are over your 90 day period? Or almost there? They can not report and sanction you for something they can not prove. As long as you have a RX stating that you take the medication. They can not fault you. Worst to worst you will be termed...

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