who should be punished

Chaya, ASN, RN · Jul 8, 2008

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

GooeyRN, ADN, BSN, CNA, LPN, RN · Jul 8, 2008

I dont see why this effects nurse B.

Altra, BSN, RN · Jul 8, 2008

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.

I hit the thanks button when I meant to hit the quote instead.

Several things bother me about this scenario.

1. Your friend, as a professional nurse, should be well aware of the policies on med administration/co-signing at her workplace, or at least well able to look up the applicable policy. The policy should delinate exactly what is required when a nurse co-signs with another nurse.

2. "Who should be punished"?? "Yellow cards"?? Is this a professional workplace or a kindergarten with a bulletin board indicating how well-behaved the children have been today? Reprimands & corrective actions are sometimes necessary but this is not how things should work with employed adults.

I realize this post may seem harsh, but I am not getting a pleasant picture of your friend's workplace. I hope she is able to move on to a better professional environment.

christine_chapel · Jul 8, 2008

Nurse B appropriately checks the name of medication, expiry date, preparation and countersigns the medication.

I see nothing here about route or administration rate, so I think that Nurse B did what she was asked to do, and did it correctly.

Seconding the motion that it's NOT about "blame" or "who should be punished," but it's about "how can we stop this from happening again." A culture of fear in the workplace is not healthy, especially when such situations are common. Nurses should be able to take the necessary time to do things correctly, not constantly be looking over their shoulders in fear.

pinksugar · Jul 8, 2008

I agree with Wooh. Nursing is so punitive. Why should anyone be punished? People make mistakes at their jobs everyday. Just because someone is a nurse or doctor doesn't make them perfect. Instead of trying to punish Nurse A or B, why isn't there a study to get to the real problem? Are staffing levels unsafe? What is the floor's acuity at the time of the incident? How many patients and family members were asking Nurses A and B for water and blankets at the time of the incident? :banghead: Etc., etc.

**SKM-NURSIEPOOH, BSN, RN** · Jul 8, 2008

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.

i just wanna get the scenario straight :confused:

.

nurse a gave x2 bags of levophed instead of x1 bag of levophed & x1 bag of ca gluc? and nurse a ran that second bag of levophed at the rate that the ca gluc would run :uhoh21:?

thx - moe

**SKM-NURSIEPOOH, BSN, RN** · Jul 8, 2008

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.

the facility i worked at had a similar high alert or high risk policy whereby both nurses are signing & co-signing that all checks were made....right down to the tubing being labeled in two places as well as checking the iv pump & rate. if this facility has such a protocol, then i could see where nurse b might be affected.

the problem i have here is, what's to stop nurse a from changing the second bag (which was verified by nurse b), & adding to it or completely changing it after it was up & running? in this case, the error would be nurse a's & nurse a's alone...right?

i hear the majority here regarding the blame game, but isn't pinpointing the error the important thing? what if some professionals are afraid of facing any responsibility for their own actons? how then can we begin to "fix" the quirks in the system?

just a thought - cheers,

moe