What happens when a nurse follows core medication safety principles, but misses one policy step, and is left to face the consequences alone?
An RN submitted a question about a clinical issue that she is now facing potential disciplinary action.
According to the RN, she failed to scan an oral medication she gave a patient who was considered a “failure to thrive” patient. The patient’s NJ tube cracked, and she was assisting the surgeon by getting supplies while an attempt was made to repair the NJ tube.
The RN stated that she followed the “5 rights” of medication administration but didn’t scan it. The nurse noted that the policies and procedures regarding medication scanning were lax and expressed concern that the nurse manager had not advocated for better guidelines.
She asked why she is accountable for this medication administration error, but the nurse manager and the facility aren’t accountable for developing better policies and procedures.
The RN’s concern is valid and reflects a broader issue in healthcare systems. In this case, the medication error didn’t result in a patient injury or death.
Learning from the RaDonda Vaught case
This example is reminiscent of the RaDonda Vaught case, in which a medication error resulted in a patient’s death and how that error was handled by both her employer, the board of nursing, and her practice state’s criminal justice system.
I previously explored the importance of adhering to standards of practice in medication administration, using the Vaught case as a key example.
You may wish to revisit that blog for detailed guidance on proper medication administration practices, including the importance of reporting errors without fear of reprisal. Because while these guidelines may seem basic, it is often the foundational practices that are most frequently overlooked.
The danger of a blame-first culture
Blaming this RN and other nursing staff who commit a medication administration error doesn’t resolve the problem of poor policies and procedures that are either poorly developed or not updated as needed.
A non-punitive system for reporting medication errors to nursing leadership and risk management can help identify and correct systemic flaws.
How just culture supports safer medication practices
The non-punitive approach to medication errors (and other patient care errors) by nurses and other healthcare professionals has been acknowledged as a just culture approach.
Once reported, nursing administration and risk management have the responsibility to analyze the error, adjust policies and procedures that affect that error, and establish safer approaches to administering medications.
The just culture approach also provides nurses and healthcare staff the opportunity to learn what their role was in the error made and incorporate that learning into future patient care. In essence, just culture is grounded in accountability and learning, not punishment.
How nurses can respond
This RN’s concerns highlight broader issues surrounding medication administration that many nurses face. Fortunately, no harm came to the patient in this case.
However, the RN now faces a potential disciplinary action due to her failure to scan the medication administered. She should use all grievance options available to her within her place of employment and follow those guidelines carefully.
Consulting with a nurse attorney or healthcare attorney may also help her navigate the disciplinary process effectively.
Reporting unsafe leadership and facility practices
The RN should also consider whether filing a report with the state board of nursing is appropriate. If there is factual information that the nurse manager is not fulfilling their role and leadership responsibilities as required by the nurse practice act, the RN may be obligated to register a complaint with the state board of nursing.
Similarly, if the facility as a whole isn’t addressing safety concerns related to medication administration, a report may be submitted to the appropriate state licensing body. Again, any such report should be supported by factual information.
A nurse attorney or attorney can provide more specific legal advice about these options.
Why staying silent about safety concerns puts nurses at risk
Keep in mind that not voicing concerns about patient safety, especially those involving medication administration, can result not only in an injury to a patient but can also leave you as the nurse vulnerable to being held solely responsible while safety issues continue to exist.
