When Doing The Right Thing Leads to the Wrong Results

Submitted by Tracy Nelson-Bungert, RN, MSN

Tags: Case Study errors medication medication errors mental health prescriptions punishment termination due to medication error

When Doing The Right Thing Leads to the Wrong Results

Share Article:

As nurses, we are taught, above all else, to keep our patients safe. What then, happens when nurses cannot fulfill this obligation- when the very system that nurses work in is not conducive to doing the right thing? When nurses take responsibility for their shortcomings and errors due to a dysfunctional care system, but lose their license and livelihood in the process?

The 2006 report from the Institute of Medicine of the National Academics states that preventable medication errors harm 1.5 million people every year. (Institute of Medicine of the National Academies, 2006). A 1995 Journal of American Medical Association (JAMA) study reports that 39% of the errors occur during prescribing, 12% of errors occur with the pharmacy, and 39% of errors occur during administration (Bates DW1, 1995). This means, as nurses administering medication, if an inaccuracy is going to occur, there is a considerable chance the order is incorrect even before it gets to the nurse.

Medication errors are the looming cloud dangling over all nurses’ heads working in a healthcare facility. Nurses learn the five “rights” before ever administering medication to a patient. These five rights have now expanded to eight rights. The five traditionally known rights include: Right Patient, Right Medication, Right Dose, Right Route, and Right Time. These five Rights are now joined by three other Rights: Right Documentation, Right Reason, and Right Response.

But what about doing the “Right Thing”? In this case, a ninth right- the “Right Thing” should be to report a medication error when made. As nurses, administering medication is typically the bread and butter of the job description. And nurses need bread and butter to live on, and to support their families. So if a nurse should happen to make a medication error, should they report the mistake and risk discipline which could lead to termination and suspension of nursing licenses?

Root cause analysis study reveals that examining the error to learn from it and possibly prevent future errors is the goal of any improvement process in relation to medication errors (Agency for Healthcare Research and Quality, 2011). Punitive reprimands may prevent this analysis to occur, as those reporting the errors fear consequences to admitting the misstep.

Case Study:

Jeff is an RN at a mental health care facility. At this care facility they utilize the Omnicell system for administering medications. The Omnicell system is a preloaded medication dispenser with medications for patients at the facility. The Omnicell system is loaded with medications for each patient, including as needed (PRN) medications. The system can be overridden if an emergency occurs in which the patient must receive a medication quickly.

Jeff works as charge nurse on his unit occasionally, however during this incident he was not the charge nurse and had his own assigned caseload of patients. The unit where Jeff works consists of patients that are committed to be there through the court system- many have histories of aggressive and violent behavior along with mental health diagnoses.

An emergent situation occurred where a patient required a medication quickly to prevent harm to the patient and the nursing staff. A patient with a history of violent behavior towards staff was out of control. The patient’s nurse was not available and the charge nurse was not to be found. Jeff needed to act fast to deescalate the situation. Jeff used the override function of the Omnicell to obtain the medication needed to give to the patient. Unfortunately, he did not give the patient the correct medication. Jeff could have easily buried this error in the system as it was not his patient, yet chose to report the incident.

Because this was not the first medication that Jeff had self-reported (doing the Right Thing), Jeff was terminated for cause. Because Jeff was terminated for cause he could not receive unemployment. Because Jeff was terminated he had to submit special documentation in order to renew his nursing license which would expire two months after his termination, including documentation of his continued education credits. Because the facility that he worked at had this information and would not send this to him in a timely manner, (and when they did send it, the documentation had the dates of classes cut off) he risked nursing license suspension. Because Jeff did not have an active nursing license he could not be employed as a nurse. Jeff is currently working as a nursing assistant for less than one half of what he was receiving as a nurse, and will be negotiating with the Board of Nursing to keep his nursing license for the foreseeable future.

Jeff had received a black eye and broken nose while working at this mental health care facility. His fellow staff members believe him to be an idiot for reporting the medication errors. The nursing aides that worked with him wondered why he did not just hide in the bathroom like everybody else when these patients started to get violent. Jeff’s peers in nursing cannot believe why any nurse would want to work in the mental health field, let alone work at the mental health care facility where Jeff was employed. Many of the nurses that Jeff worked with during his course of over ten year employment either promptly left after starting at the facility once they obtained a different (better) position. Many of the ones that chose to stay were, like Jeff, terminated for cause.

Jeff’s case is a cautionary tale for self-reporting medication errors. Jeff was a long term employee at a mental health care facility with a high turnover rate in staffing. If would seem that a more prudent approach to the facility’s termination of Jeff would have been to examine the error and explore ways to improve the care delivery system. The particular medication error did not result in harm to the patient and action was taken quickly by Jeff by informing the attending MD of the error when it occurred. Jeff took responsibility and owned his mistake. Jeff did the Right Thing. The Right Thing, in this case, resulted in the wrong results.


  1. Agency for Healthcare Research and Quality. (2011). The Investigation and Analysis of Critical Incidents and Adverse Events in Healthcare. Washington, D.C.: National Quality Forum.
  2. Bates DW1, C. D. (1995). Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. Brigham and Women's Hospital, Department of Medicine . Boston: JAMA.
  3. Institute of Medicine of the National Academies. (2006). Preventing Medication Errors. Washington, D.C.: The National Academies Press.