Who's medication error was it?
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I'm a new grad RN (May 2010) working in a prison on the 7a - 7 p shift. (For a little background, the oncoming day shift arrives before night shift finishes morning pill call, so we have to wait until it is over to do our turn over).
The majority of the inmates speak little or no English, mainly Spanish (of which little of the staff speak). Today at evening pill call, two inmates who share the same last name approached the window and told me that one of them had received the other's medication at morning pill call. I got their ID cards from them and found their MARs in the book, one right in front of the other. Sure enough, exact same last name. The inmate who had received the wrong medication was supposed to get Naproxen, the other (who said he didn't even GO to morning pill call) was supposed to get INH and B6. When I checked the MARs, the INH and B6 had been signed off for the inmate who was supposed to have gotten it, and nothing had been signed off for the one who actually got it. The inmate who got the INH and B6 (having the other inmate translate) accurately described the four pills he took. There was not a doubt in my mind as to what had occured (wrong inmate got the wrong meds). I administered the INH and B6 to the inmate who was supposed to have gotten it, circled the initials of the person who had incorrectly administered them this morning, and put my initials on the MAR (this is the way I have been told to document a med error).
The nurse who relieved me tonight is the same nurse who administered the meds this morning. I explained to her that the inmates came to the window and explained the situation. I told her what I did to try to correct the situation. She is a kind but brash person and immediately went into a tirade (sorry, but no other word) about how she didn't make a mistake and that the right person got the right meds, as proven by the MAR. She then told me that it was MY error for administering the dose, saying that I double dosed the inmate (I firmly disagree). She said that I should have withheld the medication and told the inmates to return to morning pill call to discuss the situation with her. In hindsight, that probably would have been the best course, but I know that patients with TB must stay on track with their medication and he was already going to be short one dose, I didn't want him to be short two. (BTW... neither inmates has any allergies, thank God... that was the first thing I checked when they told me what happened).
The nurse also told me that the inmates were playing me because they wanted more medication. I completely disagree. If the meds in question had been narcs or NSAIDS or really any other med, I would have refused to administer more meds and sent them away more than likely. However, the inmates on TB therapy or prophylaxis KNOW that they MUST get their medications on schedule and all of the ones on it so far are really good about it. Not only that, they're not going to get a high or sleep better (a big goal of some of the inmates) from taking INH and B6. Why would someone lie about those particular meds??
What SHOULD I have done? Is this now my error because I documented?? At the time I felt I handled the situation correctly and didn't question it until the other nurse started her tirade.
I'm concerned because if this does fall on me, that will make it appear as though I have two med errors (the other one was my fault: It was another case of nearly identical names, I handed some KOP/SAM meds to an inmate through the window and sent him on his way. Within seconds, I realized what had happened and had the CO call him back (he was only yards from the window). He came back to the window and I told him I needed the meds, he handed them back and I saw he had already taken one (again, thankfully no allergies!! I always check for allergies before I give ANY med and until recently I felt that I am very careful checking names and inmate numbers, but I've already learned to check and recheck those since this event)... anyway, I immediately called my supervisor and we are meeting next week to discuss the situation.
Anyway, if the situation today comes back on me (which I'm sure on paper it appears to), it will look as though I have TWO in a week!! When in reality I "only" have one. In both cases, I made certain to put a name alert on the MARs involved.
I feel I handled these situations ethically and honestly, but I would like to hear some opinions, please. Thanks!