who should be punished

I have a given scenario here where I am not able to understand whom to blame, so I would be fortunate if you give me your advice.

Nurse A is looking after a patient who is having NorAdrenaline infusion running. Before its about to finish she calls for Nurse B to check her other bag of NorAdrenaline infusion, which she is about to prepare. Nurse B appropriately checks the name of medication, expiry date, preparation and countersigns the medication. However after a short while when Nurse A is told to give Ca Gluconate as well, she confuses herself with 100ml NorAdrenaline and 100ml Ca Gluconate bag and causes drug error.

In this given scenario should Nurse B be punished as well for the drug error.

I would appreciate your advice.

Thanks.

Going exactly by your scenario, it sounds as though Nurse B did all she was asked to do. I don't really see where she is involved at all. That's sort of like asking if Nurse A asks Nurse B to check her insulin in a syringe and then Nurse A gives the wrong dose lovenox, should Nurse B share the blame. ?? Unless I'm missing something here, that is. Which is entirely possible, given the hour. :)

Going exactly by your scenario, it sounds as though Nurse B did all she was asked to do. I don't really see where she is involved at all. That's sort of like asking if Nurse A asks Nurse B to check her insulin in a syringe and then Nurse A gives the wrong dose lovenox, should Nurse B share the blame. ?? Unless I'm missing something here, that is. Which is entirely possible, given the hour. :)

i agree

I agree that nurse A is responsible for the error.

Why are we looking for someone to punish? It's a med error and should be investigated, but the blame game just takes the focus off of looking into what can be done to prevent the error in the future.

This sounds like homework.

doesn't sound like nurse B had anything to do with the calcium error.

I know it may sound funny and as a homework. This has happened to one of my best friend, the one to whom I am referring as Nurse B. She told me that she has been given a yellow card which means if one more mistake and she will be stopped from administering medications. She is absolutely disturbed thats the reason I am trying to find if she really deserved this. Is she equally liable for the mistake that happened even though she wasn't present there or been called to witness when the checked Nor Adrenaline bag was been replaced.

I am not a nurse myself and I came across this site through google search. I thought this may be the best site I could get a reasonable answer since u are all trained nurses and know best. Maybe your opinions or suggestions would help her stop criticising herself and voice out towards the action taken on her.

Well, I agree it's not about punishing, and I know when I'm countersigning a medication, I am also assuming my part in checking the correct pt, med, dose etc.

If she countersigned the med and all was correct, then Nurse B did not make the error.

Do you think that Nurse B should have checked when nurse A was changing the bag. Even though in this case she wasnt called to witness it, since she countersigned the medication was it not her responsibility to make sure that its been administered through the right route.

do you think that nurse b should have checked when nurse a was changing the bag. even though in this case she wasnt called to witness it, since she countersigned the medication was it not her responsibility to make sure that its been administered through the right route.

it depends on what the facility policy says about what is involved in countersigning for meds.

for example, where i work, we don't mix levophed (noradrenaline) except in emergency situations (pharmacy mixes sends routine -- replacement -- bags). because of this, we don't have a countersign policy for it. if i made an error in mixing the drug (i'm allowed to do this where i work) and the primary nurse hangs it, the error is mine, since she is not required to watch me prep/mix the drip.

if the policy is that a second nurse verifies that the mix is correct, then i don't think your friend was in error.

but, if the policy states that the second nurse is to verify both the correct mix/labeling of the drug, and verifies that the drug is hung correctly/at the correct rate (we do this part for heparin and continuous narcotics), then it sounds like she was in error.

(i suspect that this might be the case, since levophed is considered to be a "high alert" medication, there is a good chance that the facility has a policy that the drip rate has to be verified when a new bag is started, which means that your friend would have needed to be there when the bag was actually hung.)

i see the whole med verification thing skimped on quite a bit. nurses are getting a countersignature, but aren't really verifying that the correct meds are given. anytime i try to get someone to visually verify my insulin, i have a hard time getting them to look at the syringe.

Nurse A is responsible for the error. However a policy should be inplace that prevent nurses preparing medications from disruptions of any kind. Nurses who are pulled in multiple directions at a time and are prevented from focusing 100% of thoer concentration on the task at hand make errors.

I'm not clear if nurse A had a second nurse check the Ca Gluc?