WWYD? Medical Profession related

[Judy from Boise]

Wow, I gave the medication error report to our Pharmacy and theraputics committe at my hospital yesterday, glad i didn't face some of you! There does not need for there to be a villan or punishment for every error. Patients and providers can work together to ensure systems are the best they can be. Unless you do not believe the sincerity of this MD and nurse, I would accept the apology. I also love the idea of using this a a big talk with your daughter about being an involved partner in her own care.

 

[PrincessKitty1]

As there was no harm done, I would not be reporting to the state or suing. The doctor's office admitted the mistake rather than trying to cover it up.

When my father was in the hospital with aspiration pneumonia, the hospital overloaded him with fluids and he went in to congestive heart failure. This caused him to have heart problems for the next year of his life until he died. We did not report the hospital to anybody, and we did not sue. We appreciated the fact that they admitted to the error and apologized. They could have covered it up and we would have never known what happened!

OP, I think you should try to find it in your heart to forgive. This will be a good lesson for your DD to learn to take guardianship of her own healthcare and ask questions. It's awful that an error was made, but I would not go running to the state to report the nurse or the doctor's office.

 

[Keli]

I read the first few posts and thought I was going to be the only person thinking that I don't think an official complaint should be filed with the state.
There a plenty of doctor's offices that wouldn't have told the patient what transpired. They'd slip it under the rug and hope it never came to light.
This doctor was above-board and honest and the patient didn't suffer any harm (although, of course, the potential was certainly there.) I would let it go at this point.

 

[npmommie]

Medication errors happen every day in hospitals across the country. Typically, when they are caught, because not all errors are detected, even by the person making the error, an injury/incident report is made out and kept on file. I don't know what the process is in a private practice, but clearly this isn't something that would be reported to the medical board, but perhaps the Dept of Consumer protection/nursing licensure dept. Is it a serious error? The DD hasn't suffered any injury. She isn't pregnant that we know of, so if one did sue, what would they recover? She was given a safe vaccine with no ill effects. The physician informed the parent of the mistake and apologized. Should the nurse loose her job? I think she should be reprimanded but, as a nurse, she is no doubt reprimanding herself more than her immediate boss or the state could ever do. Most nurses take their mistakes very seriously.

I agree with this.
if every nurse who has made a medication error lost their license there would be very few nurses working

at our Pedi office, I have to sign off on the vaccines given to the kids, the lot number from the bottle is written on the line, as well as the name of the vaccine.
I also take it a step further, I have the nurse draw up the vaccine in front of me in the room, so I can see the bottle.

 

[Pea-n-Me]

So this friend of mine has a 17 year old daughter, who started getting the Depo (birth control) shot a little while back - she last went for it in April. Today, my friend called the doctor to arrange for the July shot (you get it every 3 months) and they said she didn't get that in April - she got the first of her Gardisil series!

The doctor is apologizing - the records say she was there for the Depo, but got the Gardasil (the vaccination for cervical cancer).

There obviously some medical liability, as far as professional licensing, goes - she is in a real dilemma because this is her pediatrician, and if she reports the RN to the med. board she wouldn't feel comfortable bringing her other kids there. She has been happy with this doctor, should she just accept the apology, continue the series and move ahead?

BTW, she had planned to "talk" to the doctor about the Gardasil, but never asked for it. I am not sure what medical releases she signed during the appointment.

I really think this is a major screw up and should be reported to the medical board, but would like some other opinions!

I guess I'm not completely clear that this is a nursing error.

I work in a hospital and not a doctor's office, so I could be wrong.

But wouldn't there need to be a doctor's order for either a gardasil vaccine, or depo shot, to be given? If so, then you'd need to look and see what the order was -was it for the gardisil or depo?

If it was for the gardisil, then it was ordered incorrectly and the nurse may not have been in error at all.

If it was for depo, but gardisil was given, then yes, the nurse would have given that in error.

I read the OP several times and couldn't figure out which it was.

The other thing about "reporting". I know in the hospital, we are encouraged to report all problems, not in a punitive way (usually), but to alert administrators that there is a problem with "whatever". It could be equipment, systems, personnel, whatever. Many things are improved this way. So in that light, I don't know about reporting to a medical or nursing board, but once you figure out exactly what happened, maybe the administrators or managers of the office should be aware of what happened so that if it was a systems error (as in, do vaccines pop up automatically when one is "due"? They do at my pediatrician's - and my vet's! Who's to say that the DD didn't say she was here for her "shot", they looked up to see what was due - depo probably wouldn't be one that would "pop up", and administered that one that was "due", ie gardisil, just a guess what may have happened), then it can be re-evaluated.

JMO

 

[Lisa_M]

I would report the error to someone, not sure who....maybe the nurse liscensing board or health department. Although the girl has no ill effects at this point, we don't know the long term effects of this vaccine and if she was given it in error and later had related medical problems, she certainly would have a case.

I think in the future this girl should be going to a gynecologist. She is 17, the pediatrician is not an expert in women's reproductive health. Besides that, there are a lot of bad side effects from Depo. When I used it, my hair falling out and weight gain were just the minor effects. I hope this girl is truly informed about the risks. Google is a wealth of information.

 

[DawnCt1]

I would report the error to someone, not sure who....maybe the nurse liscensing board or health department. Although the girl has no ill effects at this point, we don't know the long term effects of this vaccine and if she was given it in error and later had related medical problems, she certainly would have a case.

I think in the future this girl should be going to a gynecologist. She is 17, the pediatrician is not an expert in women's reproductive health. Besides that, there are a lot of bad side effects from Depo. When I used it, my hair falling out and weight gain were just the minor effects. I hope this girl is truly informed about the risks. Google is a wealth of information.

Actually we do. The vaccine is well studied. In order to report the "incident" one needs to file a formal complaint. This error is not worth the trouble that it would cause the nurse. There is no harm. There is no injury. As you pointed out, the risks of an injectable hormone are so much greater. This girl has been sexually active, so it is unclear how much she will benefit from Gardasil at this point, but since she started, it would still be a good idea to complete the series. There is a permanent record of what happened; in her medical file in the physician's office. I agree, the girl should be seeing a gyn but she is still an adolescent and its appropriate for her to see both.

 

[Disney Doll]

See bolded

I would report the error to someone, not sure who....maybe the nurse liscensing board or health department. Although the girl has no ill effects at this point, we don't know the long term effects of this vaccine and if she was given it in error and later had related medical problems, she certainly would have a case. She could also ask for complete documentation from the MD about the incident so she would have evidence for the lawsuit. Clearly, for some posters, the next time this kid got a cold, it was going to be because she got the wrong shot, so....I think in the future this girl should be going to a gynecologist. I agree She is 17, the pediatrician is not an expert in women's reproductive health. I agree. Assuming she is taking the Depo shot because she is sexually active, there are a host of other women's health issues here that she needs to be educated about, the first one being that her healthcare is primarily her responsibility, and that she should know what she's getting, the risks and benefits of her medications, the risks of her behavior and so forth. If there is another reason why she is getting the Depo shot besides sexual activity, she needs to know that as well...what is my problem and why is this medication the one I should be taking to correct/control the problem.Besides that, there are a lot of bad side effects from Depo. When I used it, my hair falling out and weight gain were just the minor effects. I hope this girl is truly informed about the risks. Sounds like she is not an informed healthcare consumer. Google is a wealth of information. As long as appropriate and respected websites are used, I agree.

 

[luvmy3]

Medication errors happen every day in hospitals across the country. Typically, when they are caught, because not all errors are detected, even by the person making the error, an injury/incident report is made out and kept on file. I don't know what the process is in a private practice, but clearly this isn't something that would be reported to the medical board, but perhaps the Dept of Consumer protection/nursing licensure dept. Is it a serious error? The DD hasn't suffered any injury. She isn't pregnant that we know of, so if one did sue, what would they recover? She was given a safe vaccine with no ill effects. The physician informed the parent of the mistake and apologized. Should the nurse loose her job? I think she should be reprimanded but, as a nurse, she is no doubt reprimanding herself more than her immediate boss or the state could ever do. Most nurses take their mistakes very seriously.

I disagree with the bolded. This particular vaccine hasn't been around long enough to make that determination and there are plenty of information on some pretty bad effects from those who took the vaccine.
While I agree that there is no reason to sue, I think reporting to to the medical board is the right thing to do. A medication was given without consent and while it did no harm to the patient it very easily could have.

Actually we do. The vaccine is well studied. In order to report the "incident" one needs to file a formal complaint. This error is not worth the trouble that it would cause the nurse. There is no harm. There is no injury. As you pointed out, the risks of an injectable hormone are so much greater. This girl has been sexually active, so it is unclear how much she will benefit from Gardasil at this point, but since she started, it would still be a good idea to complete the series. There is a permanent record of what happened; in her medical file in the physician's office. I agree, the girl should be seeing a gyn but she is still an adolescent and its appropriate for her to see both.

As far as this vaccine being well studied, how do we know the long term effects of it? Its still too new and some parents are not comfortable agreeing to give their dd's this vaccine. Unfortunately this mother and her dd were not given the chance to do their own research and come up with their own conclusion on whether or not to get it.
Personally I would have a huge problem with this, and I would report it. To me its the responsible thing to do, who knows how many times this has happened previously or will happen again, maybe next time the patient would have some serious side effects because of a mistake like this.

Just curious, do you believe that (the bolded part ) makes it alright that the patient was given not give the depo when she was supposed to be?

 

[Judy from Boise]

I'm sorry but I find this thread so disheartening. Let's just replace all healthcare workers with robots and eliminate non malicious human error for good.

 

[daughtersrus]

Did you sign for the shot? At our Ped's office, you have to sign for every shot. The paper lists the name of the medication as well as the lot#. Which medication is listed on their paperwork?

 

[luvmy3]

I'm sorry but I find this thread so disheartening. Let's just replace all healthcare workers with robots and eliminate non malicious human error for good.

I'm sorry if you are disheartened by those of us who think a patient has a responsibility to inform the proper authorities about medical mistakes, even non malicious ones. Would you feel differently if that patient had an adverse effect from the mistaken medication, or worse a life threatening complication? Just because that didn't happens doesn't mean the error should go unreported.

 

[npmommie]

I'm sorry but I find this thread so disheartening. Let's just replace all healthcare workers with robots and eliminate non malicious human error for good.

I agree. was thinking the same thing

I can agree that a nurse that makes a med error beats herself up for sure.


once i came on shift 3-11 and got floated up to the medical surgical floor, to do a one to one with a patient. the reason was that the nurse on day shift drew up his insulin wrong and gave him like 5 times the amount he should have gotten, sooooo i took care of him all evening, again he was fine in the end, the nurse in question was horrified she did it, but it resulted in a change in policy, where nurses co sign and check when drawing up insulin, so two sets of eyes look at the insulin being drawn up into the syringe.

 

[npmommie]

I'm sorry if you are disheartened by those of us who think a patient has a responsibility to inform the proper authorities about medical mistakes, even non malicious ones. Would you feel differently if that patient had an adverse effect from the mistaken medication, or worse a life threatening complication? Just because that didn't happens doesn't mean the error should go unreported.

These errors are reported, this will be in the patients medical chart documented, she can request a copy.

 

[DawnCt1]

I disagree with the bolded. This particular vaccine hasn't been around long enough to make that determination and there are plenty of information on some pretty bad effects from those who took the vaccine.
While I agree that there is no reason to sue, I think reporting to to the medical board is the right thing to do. A medication was given without consent and while it did no harm to the patient it very easily could have.



As far as this vaccine being well studied, how do we know the long term effects of it?
Personally I would have a huge problem with this, and I would report it. To me its the responsible thing to do, who knows how many times this has happened previously or will happen again, maybe next time the patient would have some serious side effects because of a mistake like this.

Just curious, do you believe that (the bolded part ) makes it alright that the patient was given not give the depo when she was supposed to be?

To answer your last question first; NO, I do not believe that even giving an aspirin wrongly is okay. It was an error. The results of this error however is a non event. There was no harm and no injury. The doctor's office was very forthcoming about what happened, apologized, they have documented it in the clinical record. What would be the purpose of reporting this to any licensing agency? With regard to the safety of the vaccine. I believe that the following information is very reliable. I also feel that the bolded part, the recognition that the vaccine is so worthwhile and valuable, that the clinical trials were stopped so that those girls receiving the placebo could be protected is very telling. The issue with this young lady in question is, will there be a benefit to her since she has been sexually active and may have already been exposed to the viruses that the vaccine is designed to protect her against. The other issue with regard to 'safety', is not the long term effects down the road but how long the protective ability of the vaccine will last. Will there need to be revaccination? I don't know the answer to that.
Merck & Co. conducted a Phase III study named FUTURE II. This clinical trial was a randomized double-blind study with one controlled placebo group and one vaccination group. Over 12,000 women aged 16–26 from thirteen countries participated in the study. Each woman was injected with either Gardasil or a placebo on Day 1, Month 2, and Month 6. In total, 6,082 women were given Gardasil and 6,075 received the placebo. Merck has tested the vaccine in several hundred 11- and 12-year-old girls. On February 27, 2006, the independent Data and Safety Monitoring Board recommended the clinical trials be terminated on ethical grounds, so that young women on placebo could receive Gardasil.
As of February 2009, 40 million doses of Gardasil had been distributed worldwide, with no evidence the vaccine has caused serious adverse effects. According to the Centers for Disease Control, the vaccine was tested in over 11,000 women and girls (ages 9 to 26). The Food and Drug Administration and Centers for Disease Control say that the vaccine has only minor side effects, such as soreness around the injection area. The FDA and CDC consider the vaccine to be safe. It does not contain mercury, thiomersal or live virus or dead virus, only virus-like particles, which cannot reproduce in the human body.


Of the 23 million doses of Gardasil administered to girls and women up to December 31, 2008, 11,916 adverse events were reported to the Vaccine Adverse Event Reporting System (VAERS): 94% of these events have been classified as non-serious with the remaining 6% classified as serious. Gardasil has less than half the average percentage of serious reports. These are anecdotal reports, and "it is important to note that a report to VAERS does not mean there is a connection between the vaccine and the event. It means the event took place following vaccination."The FDA and CDC said that with millions of vaccinations “by chance alone some serious adverse effects and deaths” will occur in the time period following vaccination, but have nothing to do with the vaccine.Although at least 20 women who received the Gardasil vaccine have died, there is no evidence that deaths or serious outcomes were connected to the shot. Where information was available, the cause of death was explained by other factors. Likewise, although a small number of cases of Guillain-Barré Syndrome (GBS) have been reported following vaccination with Gardasil. there is no evidence linking GBS to the vaccine.

 

[DawnCt1]

I'm sorry but I find this thread so disheartening. Let's just replace all healthcare workers with robots and eliminate non malicious human error for good.

Exactly. We all expect perfection and its nice when it happens, but do nurses and health care workers need to be subjected to public floggings and loss of their livelihood for errors that result in no harm or injury? I remember thinking when I first graduated from nursing school; "If you make a mistake as a cashier, its only money, it isn't someone's life". Nurses hate making mistakes but she did the right thing and self reported. Lets punish her some more. I also think that Pea N Me made a good point; What was the physician's order? We don't know exactly where this error began.

 

[luvmy3]

These errors are reported, this will be in the patients medical chart documented, she can request a copy.

Thats not the same as reporting it to the State or County Medical Board. How does reporting it in a patients file ensure something like that doesn't happen to any other patient that goes there? While this particular incident did not cause harm to this patient, whose to say that if and when it happens again it won't. Its not about punishing that nurse, its about making her accountable for her actions. I'm sure shes sorry and beating herself up, but IMHO she needs to have it reported in HER file.

 

[disbridemimi]

I would check all the consents to see what is signed, I am guessing they signed a consent for Guardasil.

 

[Galahad]

I would report it. This is malpractice. She could also probably sue for battery as she was subjected to medical treatment she did not consent to and it was not an emergency. This is a big deal and I would be very upset. As a PP mentioned there could have easily been an accidental pregnancy.

ETA- I suppose it would depend on how violated the patient/parent feels. My best recommendation would be to speak with Dr. and see how he explains the situation. If he has identified the problem that caused the mix up, etc. I think I was initially very shocked at the idea that she went around for 3 months w/o the birth control she thought she had. That would disturb me a lot so I would want to know the Dr. had taken every possible, reasonable precaution so that would not happen again.

It is neither malpractice nor battery. (as much as people would like, a medical mistake is not a synonym for malpractice). It should be reported but hysteria doesn't help. Why would you suggest that they talk to the doctor? It sounds to me you want them to get some sort of retribution against the doctor. Once you want that, talking to the doctor seems to no longer be a reasonable option.

 

[DawnCt1]

Thats not the same as reporting it to the State or County Medical Board. HOw does reporting it ina patients file ensure something like that doesn;t happen to any other patient that goes there? While this particular incident did not cause harm to this patient, whose to say that if and when it happens again it won't. Its not about punishing that nurse, its about making her accountable for her actions. I'm sure shes sorry and beating herself up, but INHO she needs to have it reported in HER file.

She is accountable. She reported it. Everyone knows. Its in the patient's file. Its in her personnel file. She could have kept it a secret. I wonder how many health care workers will report correctable mistakes or undiscoverable mistakes, wrong medications, wrong dose, wrong patient, wrong time, wrong route, etc, IF every time an error was made they faced a disciplinary hearing at the state level. I would guess that there would be a lot less self reporting.