School Nurse Gives Wrong Medication

NutmeggeRN, BSN · Dec 7, 2016

Unfortunately, in the school systems, there are very few checks & balances on school nursing and many nurses are required to float between two or more schools. The fact that a daily medication vs a PRN medication was administered is also concerning. In addition, I understand the parents reporting the incident to the school and board of nursing for corrective action, but I am in agreement that if they were not wanting punitive action taken against the school nurse, they would not have contacted the media.

I'm not sure the BON needs to be notified. Does that happen in every facility? For every med error?

I think that makes it punitive vs corrective.

OrganizedChaos, LVN · Dec 7, 2016

I'm starting to wonder if this "nurse" is actually a nurse. I know how people/the media will call anyone who works in the medical field a nurse. Her actions (or lack thereof) make me question everything!

OldDude · Dec 7, 2016

I had a sub nurse give an ADHD med to the wrong kid here at my campus. She was very upset and I really felt sorry for her. It didn't make the news and no real negative fall-out came from it. The prevention for this incident would have been to ask the child what their name is instead of asking the child...are you XYZ?

mom to many · Dec 7, 2016

A few years ago at the HS in my district, a student lied to the 'sub' nurse about who she was so she could take someone else ADHD med. Now at all of our campuses, we post a labeled picture of each student in our med cabinets of the ones that takes any Rx meds (daily and/or PRN). This has been helpful to me at the beginning of the year when I'm learning my kiddos that are in Pre-K and Kinder that may not be able to tell me their correct name.

JenTheSchoolRN, BSN, RN · Dec 7, 2016

A few years ago at the HS in my district, a student lied to the 'sub' nurse about who she was so she could take someone else ADHD med. Now at all of our campuses, we post a labeled picture of each student in our med cabinets of the ones that takes any Rx meds (daily and/or PRN). This has been helpful to me at the beginning of the year when I'm learning my kiddos that are in Pre-K and Kinder that may not be able to tell me their correct name.

Pictures for subs are super helpful! Since we don't have photos in my EMR (though we are working it!), I leave any sub with copy of last year's yearbook (I am also the yearbook adviser for my school and have my stock copy available) and have left post-its in the pages of my med kiddos and frequent fliers :).

BeckyESRN · Dec 7, 2016

I label all of my medication bins with the student's picture at the start of the year-not that it would have made a difference in the outcome of this situation, but I feel like it gives my subs some degree of reassurance.

kidzcare · Dec 7, 2016

At my old school the students were required to wear their IDs at all times and I also left a list with the daily meds of the student's birthdays for identification.

When I started at my current school, I had a student or 2 annoyed with me that I would look up their profile in the computer before dispensing meds. But I'd rather be safe than way sorry.

Nurse_JackieVA, BSN, RN · Dec 7, 2016

This was my biggest fear when I first started working in the school...wrong med to the wrong kid. I would keep asking the kids for their first and last names until I had their faces engraved in my brain and even then I'd still have them tell me their first and last name. I'm sooo paranoid I'm going to make a mistake and have a deadly outcome. I wish we were allowed to have pictures of the kids, we don't here but it's a huge safety issue.

abc123RN · Dec 8, 2016

I have twin boys at my school, both on ADHD med. Fortunately one is blond and the other is brunette. They take the same med but different doses. I made this note in the sub folder since they are known to try and "mess" with the subs here.

peacockblue · Dec 12, 2016

First of all, I can't believe the family went to the media. How horrifying for the nurse. They don't want her punished, but publicly shaming her is ok? Second, in one of the elementary schools I travel to, there are two blond 4th grade boys who take different meds at the same time and they are always lying to me about which one is which. Parents think it is fu ny. I do not. They are a med error waiting to happen. Can only imagine what they would do to the subs.

lifelearningrn, BSN, RN · Dec 13, 2016

I agree with everyone else.. and am really glad my district doesn't have 'standing' orders for OTC meds. The teachers would have a field day sending me kids to medicate every bump or complaint. In my district, even OTC need to have doctor's orders AND be dispensed like prescriptions (labeled from pharmisist) in order to be given. It really cuts down on cough meds, OTC pain, cough drops, etc...

LessValuableNinja · Dec 14, 2016

That's an excellent idea / helpful. We did that at a nursing home I used to work at, and some hospitals are starting to transition to doing so in the EMRs. However, it seems like in this case, simply following day 1 of clinical protocol in nursing school would have prevented an issue: Nurse: "Hey there. How can I help you?" Child: "I want medication!" "Okay! I'm going to need you to tell me your first name, last name, and date of birth." Compare to chart/mar / whatever system is used. And voila, no Ritalin for the wrong kid. Technology is helpful, but following very, very basic protocol, that you would fail nursing school if consistently ignoring, would have been preventative.