Who's medication error was it?

[NJFek]

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!

[deyo321]

First don't beat yourself up. Med errors suck, but they happen.

Myself I probably wouldn't have circled another nurses initials.

Though your investigation probably turned up the correct information you should have (as you now realize) passed the info on.

This happens in jail where the inmate will come to med pass and say they didn't get their morning meds, I can't administer them if they are signed off. ( not that I would anyway) Maybe the nurse ran out of time to go back and circle them but I usually will not call for a one time time change order.

In working with INH and B6 I probably would have called the doc and told them what I believed and then let them give me the order to give a second (presumably first) dose. This would have covered you in the event that she claimed she did give it, which she had to claim because it was signed out and you would have rested easier beliving the therapy was followed correctly.

What always chaps my hide is the inmate who takes the med looks in the cup takes the med and then says "I don't think that was mine, what was that?" Are you ******* kidding me? Too late now. The inmate who took the meds could accurately describe 4 pills that he took? Do they even look like naproxen? Which I am assuming is one pill? Geez take some responsibilty for your own health. Sorry my own rant... good luck let us know how it goes.

[Jaila]

I agree with deyo. As far as I am aware it is never ok to circle another nurses initials. It should have been passed on to the nurse that you believe made the error &/or call to the MD.

I also believe you put yourself in a sticky situation having one inmate translate for the other inmate. We have a translator service we can call. How are you to know you are not intentionally being manipulated or given incorrect information? You may have unintentionally put yourself into an legal/ hippa situation.

But as deyo said med errors happen...it sucks, but it is part of it. Don't beat yourself up. We all have made mistakes, or been in situations that we should have handled differently. I believe thats why they say hindsight is 20/20. Just learn from it and move on.

[mscsrjhm]

Where to start?

You and I know that they can't get high from INH, but other inmates don't know that. I have seen them sell antibiotics, Theophylline, HTN meds, etc for sex, commissary, and food. Maybe someone wants to collect pills to commit suicide, or to crush them and put them in someone's food.

They didn't complain when they took them, but they waited until the new nurse was on duty.

One inmate translated for another...no telling what was actually being said.

Sorry, but they played you. They got more meds, they caused a rift among the nurses, they found something to do with their time, and they laughed about it.

It is very tough for new nurses to work in correctional. So trusting. Hopefully, your co-workers can see that you were played, help you learn the system, and tell you stories about when they were "taken".

Next time, just tell the inmate, "You should speak up when you get the medication if you think it isn't correct". Watch and see, they will just walk off.

When working corrections- always talk to your co-worker first.

[NurseCubanitaRN2b, BSN, RN]

Why would someone lie about a med????? HELLOOOOO, they are in prison. They are not there for their good deeds. Trust your co-worker over an inmate any day of the week.

Also keep in mind you falsified a legal document because you circled the nurses initials that wasn't yours. I hate to say this but you made a name for yourself in this facility. Your co-workers won't trust you anymore. Just learn from your mistake & move on. Good Luck

[lvnnars1]

please dont circle anyone's initials, circling can also mean that the patient refused the medication. when you circled her initials did you write anything regarding her circled initials?

[mtsteelhorse]

The above responses are all good. Just remember, don't trust inmates. It's just the reality. If an inmate says "hey, that wasn't my med" then it truly is too late. They need to be responsible, be awake, etc. There's no way to really prove what occurred. Inmates can and will say anything. Document only what you do and do not make notations for another nurse. I have worked corrections for 6 1/2 years and constantly learn new things about manipulation. Learn from this and move on. Inmates have a responsibility, too. Best of luck to you. Errors happen...we're human. Learn from them and trust me, you'll be a better nurse for it.

[NurseCubanitaRN2b, BSN, RN]

please dont circle anyone's initials, circling can also mean that the patient refused the medication. when you circled her initials did you write anything regarding her circled initials?

When you circle initials it doesn't necessairly mean they refused the med. It can also mean the medication wasn't given. If there's no explanation, most will take it as the pt. refused.

[NurseCubanitaRN2b, BSN, RN]

I also forgot to add that any inmate that's on drugs will take ANYTHING just to get a high. It doesn't have to be narcotics or NSAIDS. I've seen cocaine addicts crush anything they can get their hands on just to snort it.

[Conqueror+, BSN, RN]

In corrections I always worked under the assumption that everything an inmate tells you is a lie. My own version of universal precautions. They have 24/7 to plot and manipulate and they are GOOD at it. They don't care if you lose everything. I never touch another nurses documentation especially if she is relieving me. If it were an emergency I would call her at home and ask her. I would much prefer you interrupt me at home than to have you tamper with my documentation. Apologize to her and move on.