Disciplinary Scenario

[Dustdevil]

You are the manager of a service that provides medics to run remote duty industrial medical clinics. Your clinics are stocked with 5 morphines and 5 valiums. They are prefilled "Carpuject" vials which come in white boxes with pink writing on them. The boxes look alike except for what is written on them.

So here is the scenario. You send out five new vials of morphine to a clinic just before their current stock expires. When it expires, the medic there follows established procedures by calling a [non-medical] management official to witness the wasting of the expired morphine. The medic examines the medicine, then the witness examines the medicine. Then they go to the bathroom where the witness hands the medicine to the medic and she shoots all five vials into the head. Both she and the witness sign the accountability form and log, and the witness leaves. After it is all said and done, the medic discovers that she accidentally wasted the good valium instead of the expired morphine. She immediately reports the error to you, her manager.

What do you do?

[BushyFromOz]

whoops

in this order....

Replace valium immediately

Account for morphine, both new and old

Recall witness

Edit drug register as necessary

Issue a bad boy pay more attention speech

Systems review and determine if the system contributed to the error. Alter accordingly

[Asysin2leads]

Recall witness

Write appropriate reports

Look into labels for boxes to prevent further occurences. Big pink stickers stating "THIS IS NOT MORPHINE, DUMMY" perhaps would be appropriate.

[Lone Star]

So, the valium was actually wasted?

Since the labels all generally appear the same (except for the written contents), something like this event is inevitible. Replace the needed drugs, document the event, recall and interview witnesses, and seek better package markings to prevent a repeat of this event in the future.

The only 'problem' I have is that both the medic and the witness examined the packages, no one caught the difference between the words MORPHINE and VALIUM?

[Shelbmedic]

Not sure how the accidental wasting of Valium would be handle in USA vs Canada.

But the Province I work out off.

Once you have been notified as the manager about this mishap (1) would be get more valium for restocking

(2) account for the expired morphine and the new Morphine. (3) The provincal Medical Director would have to be made aware. (4) The Local PD might even become involved. (4) The Medic would be Questioned about this as well as the witness at separate times plus both their actions would have to in a written report. (5) Ask how it is possible that 2 people both took the time to look at the medication name on the box and vials could have accidental still wasted the wrong DRUG..... (6) After the investigation a memo would be sent around to all bases about making sure you have the right drug. (7) Then change the type of box by marking it with a different color tape Bright Yellow to show the difference in the boxes and might even hold staff meetings to drive home the importance of BEING sure about what Drug you are wasting

[Dustdevil]

I am very pleased with the quality of these replies! Very well thought out and well stated.

Although, I am underwhelmed by the quantity. Such is the risk of posting in the proper forum instead of throwing everything into the "EMS Discussion" catch-all. :?

So, just to clarify the scenario, you, the manager, are absolutely confident that there was no hanky panky. You have no concerns that there was abuse or theft involved. You have no doubts that it was simply an unfortunate, but careless mistake.

Given this scenario, it seems that you all believe it to not be a serious disciplinary issue worthy of suspension or termination, correct? And you believe that established procedures, as well as the lack of same, are partially to blame for the incident, right?

Any other thoughts or comments? I would like to see a few more opinions on this topic from other forum members before I throw in just a little more pertinent info to see how that would affect your decisions.

By the by, this is not a trick question. I am not attempting to lead anybody into anything here. This is just a situation which I recently witnessed, and I would like to know how the attitudes of management compare to the conventional wisdom of others in the field.

[Just Plain Ruff]

1. report this

2. file an incident report

3. Call the witness to return for debriefing

4. Get replacement meds out to the site - but this is going to take a while since it's an off site facility if I read right?

5. Determine if this has happened before? If so then harsher penalties other than "DONT DO IT AGAIN"

6. Even though you are certain no hanky panky has occurred it is incumbent on you to order a drug test. That way all I's are dotted and all T's are crossed. This will be a unpopular decision but I don't see any way out of it.

Use this as a learning situation and what could be done to make it harder to not make the mistake.

I'd provide labels on each of the boxes.

Remedial training would be NOT to take the morphine and the Valium in at the same time.

Other items that could be taken out of this is a box system, put the expired valium in a Black box and the unexpired valium in the Narc box. Put the expired Morphine in a Red box and the unexpired morphine in the narc box. Take the black box in the bathroom first and waste, sign wastage/witness it. Return to room and grab red box and repeat.

No-one needs to lose their job but this sounds like it was a case of carelessness or misattention.

[chevy]

Based upon my 20+ years management experience (outside of EMS), unless this is a chronic offender with respect to carelessness (Doesn't seem to be the case by what you have written), I see no need for termination or other punitive measures beyond the "office chat" and an examination of what could be changed going forward to reduce the chances of this happening again. If we shoot everyone who makes a mistake, no one will ever own up to making one at that's not a good situation to be in. I'd even consider getting the offender involved in implementing any changes to protocol.

[JPINFV]

1. Replace meds.

2. Review personal files to determine if there is any sort of pattern of carelessness.

3. Interview the involved parties, have them submit incident reports.

4. Discipline [i can't think of a better word at the moment] (anything from "don't do it again" to termination depending on the involved parties personal history while leaning heavily towards the "don't do it again")

5. Review current policy and procedures (maybe there's someplace better waste meds then the bathroom, especially if medication handling is becoming a problem (read: cameras).

6. Send out a memo reminding everyone of proper procedure and what the roles are responsible for.

1-6. Notify proper authorities/oversight agencies as appropriately.

Personally, I'm of the opinion that mistakes will happen no matter how idiot proof the system is. I'm willing to bet that everyone, at some point in their life, has made some really stupid mistake, some easily fixed while others possibile life threatening. There is no need to have some sort of set punishment if it is reasonable to believe that the mistake was simply a mistake and everyone has learned from it.

[Lone Star]

I would have to agree about checking personnel files to see if this is a 'repeat performance'. If it is, then yes, harsher penalties would have to be considered.

People are bound to make mistakes, and if I can be assured beyond any reasonable measure that there is nothing underhanded or 'hokey' about this, then I dont see how the employees can be terminated for a flawed system.

In any event, as soon as the situation has been presented, then the employees involved should be sent to the local clinic for an IMMEDIATE drug screen. (Just to make sure it all on the level. That way it not only protects the company, but will also protect the employee from innuendo and false allegations.

In the mean time, the system that allowed an error of this maginitude would have to be seriously considered for areas of improvement and prevention.