Wrongly accused of medication error.

[iniquity]

I work as a nurse and I was told I’d made a medication error. Basically the pharmacist had noticed that a drug packet with a similar name to the drug prescribed was found in the patients locker with one tablet missing. She said I must have given the patient this tablet by mistake. I know I didn’t as I used the patients own dosset box. I’m not sure how this drug packet landed in the patients own locker but I know I didn’t make a med error. How do I clear my name?

Who found the medication, and why in earth were they going in to a patient's locker in the first place?

What is the patient's account?

It was the pharmacist. Patients have their own drug lockers where we put their regular medication. These are locked and only ward staff have access.

I don’t think the patient was told , at least I hope not as I know I didn’t give her the wrong medication. She would worry for no reason.

Has the patient capacity. Can they be asked?

Have you contacted your union for advice, if not that would be my first step

Are you a member of a union OP? If so I’d contact your local rep for support, they will have experience in dealing with this sort of accusation

The patient has capacity but wouldn’t know which drugs were administered. I have a union but I have not been threatened with anything. I just feel a bit pissed off really.

You still should contact union for advice just for peace of mind if nothing else and if accusations are taken further

Was the box definitely full when it was put in there?

If the tablet is gone from the dosset box then that supports that you gave that one, would the patient have the cognition to know if she was given wrong tablet or an extra one?

Right a statement of what you have done and contact your union rep. Is your manager supportive?

Is it NHS?

Has there been an investigation?
Is everything recorded properly?

There must be an audit trail or something - the pharmacist can't just randomly accuse you without evidence etc.
Is it an untoward incident type thing?
Surely you must have been asked to write a statement or have been interviewed for this conclusion to have been reached.

This sounds very strange.

Alot of my patients are on this common medication. I suspect I left it on my drug trolley after going to see another patient and accidentally locked this other patients medication in her locker. Which although careless is not the same as giving the wrong drug to someone. I admit I don’t always check carefully the meds I put back in a patient’s locker. There is not much time in the morning to do everything. I’m always very careful with what I administer though. I was thinking of just talking to the ward manager or writing an email. The patients lockers often have drugs in there that are not prescribed for the patient which have been left behind during ward transfers/ discharges or when the drug chart has changed, so I’m surprised the pharmacist assumed I had given this tablet.

The pharmacist filled out a form known as a datex sayings medication error had occurred and I was asked what happened by a senior staff nurse. She seemed happy with my explanation but I don’t know whether I should talk to the manager or not.

If I were you I would email your manager and the pharmacist explaining what happened and how you feel about being falsely accused.

Poor you, I'd be upset and angry too.

I don't see how one pill missing from the packet can be proof of anything. Maybe you did pop one out but it fell on the floor so you had to pop another, maybe you were going to use the packet, popped one out but then saw the doset box and decided to discard it and use that instead. Also when I worked on a ward and my patient was on a med but had run out, but I knew another patient in the same bay was on it, I'd open up their locker and pop one from their supply. A million other innocent reasons why and not because of a drug error.

Fight your corner on this.

Also you said about the common name, maybe a nurse saw the packet in say Mrs A locker and because working in a ward is a knackering hell hole, misread the label and opened up your patients locker and put it in there thinking it was meant for her instead. That way it would have had pills missing from when they'd been given to Mrs A.

How can they accuse only you? Are they able, with certainty, to say that the only staff member to access that locker was you? How can they identify when that packet was put there on when that tablet was administered? Even if pharmacy check every day presumably that still means lunchtime, evening, night time and morning drugs are administered before pharmacy checks again?

I would seek union advice but think I would write a statement explaining that you know you didn't give that drug as you only used patient's own dossett box and leave it at that.

When you say you work as a nurse, do you mean you are a nurse, ie, a fully qualified registered nurse?

On the occasions when my family have been in hospital all medication taken has been given by the nursing staff, even things like "the pill" and my thyroxine.

Why would a hospital pharmacist go through a patient's private locker?

This sounds very odd on a variety of levels. Is this an old people's/nursing home?

Pharmacists often check a patients medication. It's not in a private locker it's in their locked drug locker which the nurses have keys to so they can administer meds. The pharmacists role is to make sure they have the correct medications especially if close to discharge or they're getting their new dosette box ready.

I wouldn't worry OP. The pharmacist has to do the datix if there is any doubt. If you have been asked for your account of what happened and they're happy with that, that should be it. There'll be nothing on your record unless you have been investigated and had numerous interviews. The patient came to no harm and you have been honest with your account. Drug errors happen every single day, on busy wards they're inevitable occasionally. Try not to worry, and just forget about it. Maybe write a reflection about the incident to get your head round it and you can use it for your revalidation.

I gave the wrong dose of Oxycodone to a patient once. The patient was completely fine, and I just had to write a reflection and it was never mentioned again.

It's a drug locker not a locker by the bedside , it's locked and only the nurses with key can get in it , or pharmacists.
Patients are admitted , their drugs brought in with them and put in said locker.
I'm assuming that's correct OP

sorry repeating PP

Patients own meds from home, their gp or a carehome and some those prescribed in hospital are often placed in a locked drawer in their bedside locker which nurses administer from and pharmacists check for stock levels, this is common practice. The drug trolley would not be big enough to hold everyone's individual medication. common meds, antibiotics, laxatives and analgesia are kept in the drug trolley so patients can have a combination of meds from their locker drawer and the drug trolley. If there is one missing from the dossett then the patient got the right medication, maybe pharmacy should ask themselves why they needed extra supplies if it was already available in the dossett, what a waste of money. If you get a incident report to answer to just state the facts, I would be majorly pissed off too.

Sorry, didnt see that it was a box with a similar name, it could have been put in their by anyone. If there are tablets being left after patients have been discharged this is something the ward manager and pharmacist need to sort out, do you use a discharge checklist, do pharmacy go through the locker with the tto prescription to check what is needed. Tablets can get left behind during bed moves, it's understandable when it's short staffed.

I work in NHS pharmacy and it is quite normal to put in an incident whenever anything potentially bad happens. It's not about you so don't worry. It just means that procedures will probably be put in place to stop it from happening again. It's important in healthcare not to 'sweep' things under the carpet and instead be open and transparent, so the pharmacist had a duty to report it. Regardless of whether the patient had taken that tablet or not, the fact it was in their locker created a chance for the patient to go home with it on discharge, which could have created been a bigger issue. That's probably more why it was reported.

I admit I don’t always check carefully the meds I put back in a patient’s locker.
Although you might not have administered the drug, by not paying attention to what you are doing makes it more likely that a mistake will be made, either by you or someone else, and placing the medication in the wrong locker could cause a medication error to be made - not only someone getting the wrong drug, but also someone else not getting the right drug.

I admit I don’t always check carefully the meds I put back in a patient’s locker.

This absolutely horrifies me and I cannot believe you openly admit it. I know nurses are pushed for time but my god checking medication carefully should absolutely be carried out to the letter. Thankfully I have my wits about me as on discharge from hospital year I was handed a bag with 'my' medication retrieved from 'my' locker. It belonged to the patient in the next bed and contained a controlled drug.