Monday, July 15, 2013

Another Medication Error

In the warped places where I have worked, there are some nurses who sign a doctor's order and then do not carry it out.  Repeatedly.  I have noticed when on night shift, during the 24 hour chart check, and on other shifts when investigating medication discrepancies, conflicting orders, or issues raised by a patient.  In all of these facilities, there is a procedure in place for reporting medication errors, which is never used.  Rather, everyone covers up for the nurse who dropped the ball, explaining, "That's how she is."

A psychiatrist ordered a narcotic for a patient.  The pharmacy sends a thirty day supply of narcotics for individual patients.  (We have no computerized medication system.)  The following day,  the psychiatrist discontinued the narcotic because the patient fainted twice.  "Lilly" signed for the order on the physician order sheet, but on the medication administration record ("MAR"), she did not indicate that the drug had been discontinued, nor did she remove the medication from the active medication cart.  So for 29 more days, the patient continued to received the narcotic from me and anyone else working, continuing to faint almost daily, with the psychiatrist shaking his head.  The error was discovered when someone submitted the narcotic to be refilled by the pharmacy and then pharmacy called to ask why, as the medication was discontinued weeks earlier.  The patient has not fainted since the drug was removed.

There is a 24 hour chart check for the night shift to do, which would have caught Lilly's failure to indicate that the drug had been discontinued on the MAR.  "Everyone knows that the night shift doesn't really check," is the general observation.

One of the supervisors met with me to "counsel" me on my "medication error," as I repeatedly gave out a controlled drug that had been discontinued.  I maintained that the checks in place to prevent this error were and continued to be blatantly disregarded with the blessing of administration.

"Lilly rarely fully carries out an order and nothing ever happens to her," I protested.

"You did not report this as a medication error," the supervisor explained, "so we can't fault Lilly.  You are the one who gave the drug."

Can't fault Lilly?  Then why is she employed there as a nurse if she doesn't have to carry out orders that she signs for?

So I located the forms and submitted the report.  Multiple copies.  The next day, I saw the guy from the pharmacy who is in charge of investigations.  I was on a different ward and asked him if he received my report.  "No," he answered.  I expected that.  They intercepted the report to protect Lilly, one of their favorite children.  I handed the pharmacy guy another copy I had with me.  He said, "I don't usually get these, even when I tell your supervisor about errors and tell her that reports are required.  I think she has only ever given me three reports this year, and they were all about you, even though I didn't see how you were associated with any of the errors."

Word must have spread.  The next day, one of Lilly's supporters started screaming at me from one end of the hall as soon as she caught site of me.  "What is your problem?  You are a back-stabber.  Nobody died.  Do a reality check.  You are overreacting.  So a patient got a little pill and nobody is hurt, but you have to blow this up like it's the end of the fucking world."  She was screaming as she raced down the hall at me, accusing me of overreacting.  In psych, we call that "projection."  And yes, this was a hall with patient rooms, complete with patients and staff present and watching.

I started training in a particular martial art with a place near my home.  I have not mentioned this, but I feel more confident around these physically aggressive coworkers.

As she approached, I walked towards her so I would not have to retreat as she approached.  She stopped.  "Move out of my way," I said firmly to her.

"No.  Not until you give me an answer.  I want to know why you . . ." she started ranting again.

I cut her off.  "Move out of my way now, or I will move you."  I stared at her dead on.

And she stepped aside!

I don't like to be physical or aggressive, but my coworkers do not seem to understand any other response.

The really unfortunate part is that when a really serious error is made and higher officials find out, they will want someone to pay, and administration will aim at me.  It's more than a risk of being fired.  I could lose my license and my ability to earn a living.


  1. I am afraid for you. I went and observed hearings at my BON, and all of the cases brought before the board were for nurses turned in by their peers/coworkers. None of them were patient initiated. CYA honey.


  2. Ditto, +10.
    Make and keep copies of everything.
    Document fastidiously.
    Which includes a personal journal of all these incidents, with names named, and the who/what/when details. Daily if possible, regularly without fail. Because nothing - NOTHING - scares the h*** out of risk management and HR people like finding out Nurse X has a map of who said what when and to whom, and where all the bodies are buried.
    And seriously consider spending a small amount for an hour's time in consultation with an employment attorney regarding what constitutes a "hostile work environment". You also ought to ask about your state's laws on recording conversations. If you don't need others' consent, the tapes are admissible, if need be. If the law requires the other party consent, what you do is your own business providing you're the only one who knows, and there's nothing that prevents you from taking a recording home to precisely transcribe statements, without bringing them forward or admitting their existence at any point. Most smartphones have a voice recorder feature built in.

    Start setting aside emergency money for a rainy day/sudden unemployment, also for a lawsuit fund, and update your resume(which everyone should do annually at least anyway).
    Ignoring the problem won't make it go away, prevention and mitigation will give you some peace of mind, and if things calm down at some point, you'll have a nice slush fund for a personal vacation somewhere nice.

  3. Thank you for your comments and concerns.
    This is tough to read, but true.
    Nurses are so vindictive.
    I have started taking pictures of people doing the wrong thing as well as errors in charts. I am hoping that developing a repository of evidence will be my Get Out of Jail Free card.