Read. The. Bottle.

Everyone makes mistakes. In the medical field, they tend to be less forgivable as we are tinkering with people's health, but still, mistakes happen. Yesterday afternoon I received an email from a secretary stating that the medication bottle and doctor's orders for a student directed her to give 1/2 tablet, but that the other secretary that had been giving her the medication since school started three weeks ago had been giving the student an entire tablet. According to that other secretary, she was doing that because I'd told her to. 

My first reaction: WHAT. That other secretary had previously asked me to confirm that the brand name in the doctor's orders corresponded with the generic name of the drug on the bottle that was dropped off, which I did. I didn't look at the dosage as we'd received the same medication for this student's sister, so I only confirmed the name of the drug on the sister's order, and moved on with my day. I don't dispense the lunchtime medication for students as I am taking care of my diabetics at other sites then, and the secretaries in the district get a stipend for medication administration. 

I'll admit that I should have checked the medication of the sister as well, but I do not check in and review every medication. If I did that, students would have to wait up to a week to receive it after I was able to review it, as some sites I only get to once a week these days. Far more concerning was that the other secretary had been giving an entire pill for three weeks, when it is clearly labeled on the bottle to give only half, and on the doctor's orders as well. An occasional mistake I could understand. But to do it every day for 3 weeks is a much larger mistake. Apparently the secretaries aren't taught the 6 Rights, something I will be discussing with our lead nurse when she returns from vacation. [Yes, the lead nurse took a week vacation the third week of school. Awesome.] If they are getting a stipend for administering medication, shouldn't they have some training too?

Then I had the pleasure of calling the mother about this. I have never been so nervous to make a phone call in four years in this job. It was all for nothing: the mom said she wanted her to be receiving 10 mg, not 5 mg, and was frustrated at my insistence that we get new doctor's orders to reflect a 10 mg dosage instead of a 5 mg dosage. I tried to suggest she be the one to split the pills in half, but that didn't fly, and I was afraid to draw attention to the fact that our school had been over-medicating her child for the last three weeks, so I relented and told her I'd cut the remaining pills. 

<Sigh.> That secretary got off lucky this time, as I think we got one of the few parents who was totally unconcerned her child had been receiving twice the medication she should have. The scariest part is that the secretary thinks *I* am the one who got off lucky.