Performance Report -Med Error

Nurses General Nursing

Published

I'm so sorry but I just want to vent my disappointment towards myself. Did anyone here made a med error in the homecare setting? I'm an LPN working for a private homecare company. I have a client that has his meds in a detachable blister pack that's individually labelled. I happen to give the meds one day ahead. The client told me that pharmacy put the wrong date on that is why it was one day ahead. It was the same meds that he takes every day as it says on the main label, I made a wrong decision of just giving it assuming the dates will get fixed but the supervisor on call told me I should not have given it because that was not following the 7 rights. She told me I should've reported the incident that the meds were labeled wrong and did not decide on my own. She told me she will report me and will make a performance report. I admit I made a wrong judgement and I am accountable for it. I'm just anxiously stressed what kind of punishment I will be facing when I get a call from my immediate supervisor. I'm so ashamed of myself. I'm usually very diligent with reporting things but I don't know why it didn't cross my mind that it will be a big concern.

Specializes in Case manager, float pool, and more.

Although you should have reported it ( not so much your error as it seems this was a pharmacy error ), I would not sweat it.

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Specializes in Geriatrics, Dialysis.
Yes. I had the right meds, right patient , right dose and right time. It's just I gave the blister with the wrong date. There was no supper pills with the right date so I took out the one from the day after. They told me I can't do that and I should've not went ahead and decided on my own because it screwed everyone else. I only see client at supper and bedtime for meds and insulin. Her morning and lunch visits are done by health care aides. HCAs are not allowed to give meds unless it is packed in blisters or ATC rolls. They told me I did not follow protocols that when I realized that the meds were labelled one day ahead, I should've reported it to the office. When it happened the first time, I told the client how come your pills are dated one day ahead. She said oh "Pharmacy did that, I'll let them know." So I gave the meds thinking it was the right date just printing error. I didn't think of reporting it. It got corrected the following day. Someone relabelled the dates by hand. Then it happened again and I got used to it and so are the morning staff who are HCAs. I'm just the one being crucified because I'm the one with the license. I admit I made a mistake of letting it happen ongoing for a few days. =(

I guess I'm not as much a stickler for the rules as your supervisor. I wouldn't even begin to describe this as a med error. You gave the right meds to the right patient, the only potential "error" was the med packet was dated incorrectly by the pharmacy. It sounds like the correct option according to your supervisor would have been to not give the meds at all until pharmacy somehow delivered the meds labeled correctly to this patients home. Considering you say it was supper meds, how soon do you think you could've received the correctly labeled packet?Does your patient have a 24 hour pharmacy that would've delivered them quickly? Sounds more like an error to me to miss a dose completely or give it extremely late because you are waiting on pharmacy to correct a date.

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Specializes in med-surg, med oncology, hospice.

A few years ago I was working a circulating nurse on step-down giving breaks and doing accuchecks etc...I had one patient diaophortic, slurring words et al, her BS was 30 so I gave her an amp of D50, told the primary nurse and going to recheck, primary nurse freaks out saying we need orders from the doc. I let her know we did not have to wait and that the patient could well die in interim. I do not fault the new nurse as she has been apprised by the facility critical thinking is neither required or desired. QUOTE

I know I'm off track from the original post, but just wanted to mention this is why it is important to know the hospital protocols. In my hospital, getting a blood sugar that low, meant a full amp of D50. Then recheck the BS in 15 minutes and if still low, repeat. And repeat PRN. Once the patient is safely out of the woods, then call the doctor and let him know what actions had taken place. He will want to reconsider changing the dosage and/or timing of the meds. Considering what she was admitted for, he might even put her on an insulin gtt which has its own protocols.

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Specializes in Psych (25 years), Medical (15 years).
I gave meds at the wrong time and did not report it. It is still considered an error.

Yes. I had the right meds, right patient , right dose and right time.

Okay, Im confused. Did I miss something?

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They have strict protocols in Homecare here especially we are a private company working under contract for the government. There is not much room for flexibility. I might be able to explain that it cannot be considered a med error but I will still be reprimanded for not following their protocols and letting it happen (giving meds dated one day ahead as per pharmacy label's printing error). I had other LPNs who did the same when I'm not seeing the client but I don't want to pull them down with me in this ordeal I'm going through. Like I said everyone was aware that the meds were printed one day ahead and they are giving it. I'm just the one who's see's the client on a regular basis. Besides, they might deny it. Tomorrow is when I hear from my supervisor and I have no idea how she will process the performance issue with me.

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If this had happened in any of the facilities I ever worked at and a report was required, all the facilities would have ground to a halt. And I don't agree that you should be the only person punished for not following a policy, when so many others don't find it necessary to follow that policy.

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Knock off the ashamed stuff. We are nurses that have decided to spend our lives taking care of sick people.

Somehow the pharmacy check was not only lost, but it caused you to make an error. Your supervisor has too much time on her hands . There are thousands of home care agencies begging for your labor.

Think about it, take care of yourself for a change.

I agree in principle but her boss has threatened her with a write-up, so she is worried. People have been fired for less.

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They have strict protocols in Homecare here especially we are a private company working under contract for the government. There is not much room for flexibility. I might be able to explain that it cannot be considered a med error but I will still be reprimanded for not following their protocols and letting it happen (giving meds dated one day ahead as per pharmacy label's printing error). I had other LPNs who did the same when I'm not seeing the client but I don't want to pull them down with me in this ordeal I'm going through. Like I said everyone was aware that the meds were printed one day ahead and they are giving it. I'm just the one who's see's the client on a regular basis. Besides, they might deny it. Tomorrow is when I hear from my supervisor and I have no idea how she will process the performance issue with me.

Just tell the truth.

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Thank you all for your kind words. My supervisor told me not to worry about it. She did not think I made a med error. She just told me to make sure to report report report report next time it happens. I told her everything and I am accountable for the mistake I did and I'm not taking it lightly.

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