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01-28-2013 at 10:58 AM
kxp004
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nbr: dangerous mistake

so my younger brother takes meds at his school nurses office for his ADHD and my mom went in today to refill his bottle... but found it was already full... with 60 pills she had never seen before and that WERE NOT my brothers medication....

This is violating all sorts of rules wouldn't you think? even if it was a genuine mistake that seems really dangerous to me if he took somebody else's meds....  what would you ladies do and who would you talk to? am I blowing this out of proportion by telling her she should have torn someone a new one? I would have been livid! 

 

ETA: New info... she went in and the bottle had been filled with another kids medicine by the nurse... he would have received the medicine tomorrow had my mother not gone in to refill it... the nurse wasn't too worried according to my mom... said "oh it's a good thing you came in today and caught that"

who do you go to over the nurse?


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01-28-2013 at 11:14 AM
kellyrn995...
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She should have spoken to the nurse to find out what happened. If she didn't get good answers, she should report it to someone higher up.

The sad truth is that nurses are human and make mistakes. It is terrible when it happens, but it is reality. Honestly, "Tearing someone a new one" won't do any good - it has to be reported through the appropriate channels, and looked at to make sure processes are in place so that it doesn't happen again. In the hospitals, medication mistakes are made every day. Luckily most don't make it to the patient; however, there are reporting processes so that we can work to ensure that the mistakes can be prevented in the future.


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01-28-2013 at 11:18 AM
starting a...
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I completely agree with PP, this situation is a MUST to be investigated. Even it being a mistake needs to be addressed so that it doesn't happen again!!

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01-28-2013 at 11:25 AM
sofamonkey
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kellyrn9956:

She should have spoken to the nurse to find out what happened. If she didn't get good answers, she should report it to someone higher up.

The sad truth is that nurses are human and make mistakes. It is terrible when it happens, but it is reality. Honestly, "Tearing someone a new one" won't do any good - it has to be reported through the appropriate channels, and looked at to make sure processes are in place so that it doesn't happen again. In the hospitals, medication mistakes are made every day. Luckily most don't make it to the patient; however, there are reporting processes so that we can work to ensure that the mistakes can be prevented in the future.

Yup.  Start by talking to the nurse. 

Also, if you start tearing someone a new one, you are less likely to get anywhere.  Instead of gathering info & finding out what happened, it's just you yelling.  That's not very productive in (dare I say) most situations.  Being upset is fine.  Being upset & not having any control over yourself, not allowing any info to be gathered & dealt with is kinda reckless & useless. 


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01-28-2013 at 11:26 AM
UberBiz
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Unless she goes in unnoticed and refills the bottle herself with no one watching, I'm assuming she had to have talked to at least the nurse about it already? If my child was taking medication regularly at a school, I'd make sure I had an open communication about it with the nurse (or whoever administers it).

The answer to what SHOULD she have done rests on what actually happened.


 
01-28-2013 at 11:29 AM
Idani
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I don't think you are overreacting but I agree with the PP about handling it.  I would have requested to speak to the nurse in charge, find out their policy on refilling etc and if it seemed like a genuine mistake, I would have probably been ok. However if not I would have then asked to speak to someone higher up. I don't think it's a situation to be taken lightly but I think finding out the facts would be my first step. 

 
01-28-2013 at 12:15 PM
Teacher Cl...
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Nurses are human too.  Have you never made a mistake?  IMO our society is too litigious and people forget that we are all human.

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01-28-2013 at 12:16 PM
sararn2004
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kellyrn9956:

She should have spoken to the nurse to find out what happened. If she didn't get good answers, she should report it to someone higher up.

The sad truth is that nurses are human and make mistakes. It is terrible when it happens, but it is reality. Honestly, "Tearing someone a new one" won't do any good - it has to be reported through the appropriate channels, and looked at to make sure processes are in place so that it doesn't happen again. In the hospitals, medication mistakes are made every day. Luckily most don't make it to the patient; however, there are reporting processes so that we can work to ensure that the mistakes can be prevented in the future.

This is true. I've had to do write ups, not because I wanted to "tear someone a new one"(people in medical care are aware of the consequences and throwing a fit doesn't do anything...they already know) but because I wanted to ensure something similar did not happen again. Most mistakes are process problems not person problems.

Perhaps she sounded nonchalant about it because she knew the other kids med was something less dangerous like Claritin or something(still a big deal, don't get me wrong, but as opposed to oral diabetic meds).

If you do go above the nurses head, I would encourage you to not have the intent to get anyone in trouble but to fix a process problem. Perhaps there need to be measures put into place where there are absolutely no interruptions when giving or refilling medications(distractions cause mistakes).


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01-28-2013 at 12:25 PM
kxp004
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sararn2004:
kellyrn9956:

She should have spoken to the nurse to find out what happened. If she didn't get good answers, she should report it to someone higher up.

The sad truth is that nurses are human and make mistakes. It is terrible when it happens, but it is reality. Honestly, "Tearing someone a new one" won't do any good - it has to be reported through the appropriate channels, and looked at to make sure processes are in place so that it doesn't happen again. In the hospitals, medication mistakes are made every day. Luckily most don't make it to the patient; however, there are reporting processes so that we can work to ensure that the mistakes can be prevented in the future.

This is true. I've had to do write ups, not because I wanted to "tear someone a new one"(people in medical care are aware of the consequences and throwing a fit doesn't do anything...they already know) but because I wanted to ensure something similar did not happen again. Most mistakes are process problems not person problems.

Perhaps she sounded nonchalant about it because she knew the other kids med was something less dangerous like Claritin or something(still a big deal, don't get me wrong, but as opposed to oral diabetic meds).

If you do go above the nurses head, I would encourage you to not have the intent to get anyone in trouble but to fix a process problem. Perhaps there need to be measures put into place where there are absolutely no interruptions when giving or refilling medications(distractions cause mistakes).

yeah it's probably my short temper and crazy hormones that made me that mad... it's certainly nobody's intent is to get the woman fired, but this sort of mistake could lead to really bad results if it reacted badly with other medicines that my brother is on...  

mistakes happen, but when you're dealing with medicine and people's children I guess I became a little irrational...  however the issue should still be addressed...


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01-28-2013 at 12:44 PM
meggipi5
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As many PPs said, talk to the nurse. Also, ask for a copy of the district's policy on medications at school, if you don't already have one. I'm pretty sure the nurses are only supposed to distribute the medication and track it, not refill anyone's meds. Our district is pretty strict with that stuff.

 

I wouldn't go in with a hot temper, but that mistake certainly is a serious one. If the nurse doesn't take it seriously, report it to someone at the district office.  


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01-28-2013 at 1:18 PM
adamsabiga...
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i would definitely be very upset if this happened to my little brother who also has to take medication with his school nurse but  for his asthma. And I might be a  bit hot tempered. YES, the nurse is human but her job doesn't allow much room to make mistakes like that. It's a good thing your mom caught it before he took it but suppose it had been something he was highly allergic to? A mindless mistake can take someones life.

My main concern and goal would be to see that proper measures are in place from keeping this from happening again. It just has the potential to be a major problem if it happened to the right student with the wrong medicine.  That said I would definitely report it for the reason that the nurse needs to realize she should be more cautious and establish measures (if there aren't already) to not to let that happen again.

01-28-2013 at 2:06 PM
sararn2004
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People should report mistakes so that process problems are identified. It just seems like many PP are saying "her job doesn't allow much room for mistakes", well getting someone fired only means another human gets put in her place, meaning another person that could make a mistake if there is a process problem. I don't envy school nurses at all considering most pharmacist, pharmacy techs, doctors, nurses that work in clinics and hospitals have multiple eyes/checks for those medications to go through, while school nurses are generally the only ones. I've literally had a pharmacist tell me I saved a child's life as I was the last person to check an order that turned out to be 10 times the appropriate dose of morphine for a 3 year old(after other docs and nurses had looked it over). I've also had some near misses that were mistakes of my own. Fix the process, don't blame the individual. Meaning, report the problem in a unblaming way. If there's a problem with multiple mistakes by one nurse then that will come to light.


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01-28-2013 at 3:35 PM
dande2129
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meggipi5:

As many PPs said, talk to the nurse. Also, ask for a copy of the district's policy on medications at school, if you don't already have one. I'm pretty sure the nurses are only supposed to distribute the medication and track it, not refill anyone's meds. Our district is pretty strict with that stuff.

This is what I would do also. I think it's weird that the nurse is refilling the medication, but maybe that's just a policy/procedure that I'm not familiar with. 

I know that the gut instinct is to go off on a tangent, but like a PP said, it's likely not to get you anywhere and anyone involved is going to see the anger over genuinely wanting to ensure that it doesn't happen again.

I also agree that people are too litigious but at the same time, when you're in a profession that is directly dealing with people's lives, one needs to be that much more careful to NOT make mistakes like that. 


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01-28-2013 at 3:53 PM
somebuddie...
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I wanted to add to all PP that in addition to the nurse being more diligent (which she should have been), it's ALWAYS a good idea for the "patient" to be familiar with what their medication looks like- particularly if they take something regularly. Many pharmacies will put a sticker on the bottle that says what the pill should look like. If it's not on the bottle, it's typically on the handout that comes with it. 

This happened to my mom about a year ago except in her case, she got the wrong meds directly from the pharmacy. She only noticed the problem because the pill looked different than it normally did (different color and shape). She investigated and discovered she was given a chemotherapy drug- not her blood pressure pill!

All in all though, it sounds like it got sorted out! Hopefully it won't happen again! 


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01-28-2013 at 4:09 PM
sometimesd...
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Teacher Clark:
Nurses are human too.  Have you never made a mistake?  IMO our society is too litigious and people forget that we are all human.
 

Who said anything about suing? This isn't a minor error; who knows what medication was in that bottle? OP's son's life could have been at risk! 


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01-28-2013 at 5:26 PM
Mommymorti...
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sometimesdee:

Teacher Clark:
Nurses are human too.  Have you never made a mistake?  IMO our society is too litigious and people forget that we are all human.
 

Who said anything about suing? This isn't a minor error; who knows what medication was in that bottle? OP's son's life could have been at risk! 

Yes I agree, prescription meds can cause serious problems, especially mixing them! This is a very serious mistake.


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01-28-2013 at 7:54 PM
Octobercha...
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This should be reported to her superiors.  Some school nurses work for the school board, some work for health departments...probably varies by state.  People do make mistakes, but if these incidences are not reported, there is no way to know who has a history of carelessness.  

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01-29-2013 at 12:11 AM
sararn2004
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somebuddiesgettingmarried:

I wanted to add to all PP that in addition to the nurse being more diligent (which she should have been), it's ALWAYS a good idea for the "patient" to be familiar with what their medication looks like- particularly if they take something regularly. Many pharmacies will put a sticker on the bottle that says what the pill should look like. If it's not on the bottle, it's typically on the handout that comes with it. 

This happened to my mom about a year ago except in her case, she got the wrong meds directly from the pharmacy. She only noticed the problem because the pill looked different than it normally did (different color and shape). She investigated and discovered she was given a chemotherapy drug- not her blood pressure pill!

All in all though, it sounds like it got sorted out! Hopefully it won't happen again! 

This also happened to my friend. She was going through chemotherapy and her mother picked up her Zofran from the pharmacy for her horrific post chemo nausea. She quickly took a pill and tried to get as comfortable as she could for the night. She had tremors and sweating and shaking all night long she said. When she awoke and had more of her wits about her she looked at the pill bottle, her mother had been handed glyburide, and oral diabetic medication and she'd been having symptoms of hypoglycemia all night long. My friend could have not woken if her sugar dipped too much. It could have had a more tragic outcome than it did fortunately.


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01-29-2013 at 1:52 PM
beckajw
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Teacher Clark:
Nurses are human too.  Have you never made a mistake?  IMO our society is too litigious and people forget that we are all human.

 

This.  It seems as though parents come in and refill their child's medication bottles.  While I don't see how this can be a best practice, if that's the way it's done, then that's the way it's done.  So, apparently some other momma came in and put her kid's medicine in your brother's bottle.  That's a mistake.  Yes, a preventable one, but a mistake nonetheless.  Nothing bad actually happened.  So, in this situation, I would simply talk to the nurse, say "thank goodness nothing happened" and move on with my life.  Why go through the trouble of reporting the nurse and ruining her life.  Or freaking out on the nurse, which is unproductive and childish.


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01-29-2013 at 3:37 PM
3sthecharm
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Here is the thing. most ADHD drugs are drugs of abuse. As a pharmacist I would be concerned she took the ADD pills and replaced them purposely with something else, maybe innocuous but dangerous as hell. It may truly have been an honest mistake but I would get the tab id off the pills that wre in the bottle and see what they were.
 
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