Drugs are bad kids!

More pills than a drug dealer! That’s how today felt. 

It’s been a really tough one; possibly the toughest one in my short career so far and definitely one I will be recording for my revalidation.

I won’t tell you the effect that it’s had on my bowels but let’s just say I won’t be needing my prunes in the morning.

So what would make me feel like this? Did a resident die? Thankfully not. Did I accidentally harm a resident in my care? Thankfully not – I don’t think I could forgive myself. No…I made a medication error.

I was back at Sunshine after a 10 day enforced break. Charisma told me that the Manager had barred me from the premises after I had ‘shown her up’ with my recent CQC/QVC bonding session. She told me not to worry, “she would soon want me back. Unless hell had frozen over and they were fully staffed, they’ll be understaffed again before long and can’t do without agency staff forever”, apparently. 

So there I was knocking on the door this morning (apparently the Manager had changed the key code following my temporary banishment in case I decided to break into the premises!) to be met by the Manager who I was surprised to see there so early. I braced myself for a frosty reception. I needn’t have worried, her chosen weapon was silence on this occasion and my ever-widening shoulders were more than up to that challenge. Not sure whether the ever-widening hips are so welcome but let’s not go there.

It also turned out she had been busy for once. Her very large butt had clearly been in gear as there were no less than four new residents: Sheila M, Sheila Mac, Olive and Derek! 

I scuttled off to get a ‘comprehensive’ handover (the newbies are all lovely and have settled in well) and went to start the medsround. I couldn’t find the red ‘Do not disturb’ apron that I usually wear, but I thought it would be ok just this once. Everyone could see I was the nurse and that I was doing the meds, couldn’t they!

I had managed to give out four patient’s medications before the phone started ringing. I tried to ignore it a couple of times whilst looking around for the senior carer (who is meant to answer calls when I’m on meds) before caving in 118. Before I could get back to my meds I had helped the GP answer a query about his fax, reassured Mr J. that his mother Mrs J. was fine and comfortable; and confirmed that no I have not been involved in a road traffic accident in the last three years 118, although a car crash was imminent if this guy didn’t leave me alone. Famous last words. 

All was then going well. It was lovely to see the residents again and I felt quietly pleased when they gave me a hug or told me they had missed me. I was halfway through and up came the turn of one of our newbies, Sheila M. I flicked through the MAR sheets looking in vain for a photo to identify her with but there was nothing. I was about to go and have a look at the care profiles in the office when Senior Carer popped up (I swear she was behind the curtain). She told me that I have a lovely telephone voice and that Sheila M was in the corner behind me, where a group of ladies were finishing their breakfast; and through a hasty process of elimination I figured out who Sheila M was. 

Or so I thought. 

I’d got to the end of the medication round and was just making sure I’d signed for all the meds when a little lady tapped me on the shoulder. She told me she was Sheila M and that she hadn’t had her medication that morning. 

I felt sick. If this was Sheila M who on earth had I given her medication to? 

I hunted down my unknowing victim and found her asleep in the lounge. Senior Carer told me that this was Sheila Mac and the reason I hadn’t figured out my error was because she wasn’t prescribed any meds! Fortunately she was definitely sleeping but I was in panic mode, envisaging coroner’s inquest and the slam of a jail cell door. I pretty much ran to the Manager’s office, tears welling. I blurted out my mistake without taking a breath, certain I was in for it. Amazingly this gentle voice responded to say ‘Calm down – mistakes happen’. 

Naturally her first concern were the Sheila’s, so she set to sorting it out, even managing to send the administrator in with a cup of tea for me. Fortunately Sheila M had then been given her tablets and she told me that I had only given Mrs Mac aspirin and two paracetamol, so there was only a small chance I would be going to jail in the near future. 

Not quite sure if she was joking at such a serious time, I realised she was trying to make light of the situation as she told me not to worry. She then walked me through the whole process. She explained that she had done a set of obs on Mrs Mac and rang the GP as per protocol. The GP didn’t seem overly concerned and had simply left instruction to keep an eye on her and ring back if there were any concerns. She said she would personally keep an eye on Mrs Mac for the rest of the day. I have a new found respect for Sunshine's Manager. 

After that I was sent back to the unit to write a statement about what had happened.

Later that afternoon she called me back into the office and told me the process she had followed. She had contacted safeguarding, completed a CQC notification and written a Duty of Candour letter to Mrs Mac and her next of kin. She then went through the steps needed for a full investigation and read my statement. 

We went through what had happened and the lessons that I should take from the error. Numerous distractions, a lack of a clear identifying photo on the MARS and not getting a clear identification from someone who knew the lady had all contributed to the error. I was also not wearing my red tabard, something I will never omit again. 

The manager said that a mistake had been made, but no one had been harmed and steps would be taken to try and ensure the same mistake didn’t happen again. The CQC and safeguarding were both happy with those steps and were pleased that the mistake had been identified and corrected.

The Manager really does operate a ‘no blame’ culture and as she said to me before she left tonight; ‘These things happen, learn from it. Reflect on it and let it help to make you a better nurse’. 

So let me tell you. Not all drugs are bad kids, but a hard lesson is a bitter (but worthwhile) pill to swallow.