I had my last meeting on Tuesday,at the nursing home where Gord went for respite. Apparently, when there is a new admission or someone for respite, they take drug lists from 2 different sources. In Gord's case, it was the list from our pharmacy and the list our doctor made up when I did the papers for placement. An RN checks both lists and then transcribes the medications to their own list for their pharmacy. A second person is to check all the transcriptions and then send it to the pharmacy. In Gord's case, the RN made a mistake and put ativan as a PRN instead of a standing order. The mistake was not caught. They have put a new form in place. They have re-educated the staff and for the next period of time, the forms will go to the unit nurse manager to be checked again. The forms will then go to the director of nursing for a final check. They are going to do a weekly audit of charts and did an audit of 20% of their existing files. They accepted the blame and of course, I have that in writing.
I told them that I had trusted them and they had betrayed that trust. I said I would never forgive them.
The medical director of the facility was at the meeting. He was quite dismissive of the damage that could have occurred as a result of the ativan being abruptly stopped. He said that it has a half life of only a couple of days. He took me by surprise and I completely forgot to say that several doctors had told me that ativan has to be slowly titrated down. I was so annoyed with myself and finally called the director of care who probably cries when he hears my voice. I left him a message for the medical director and he left me a message saying that he would personally deliver it.
I thought I was done and then this afternoon, I received a call from a woman who works with the City of Toronto's risk management team. She is very anxious to come and talk to me. She was waiting for the director of care and the home's administrator to call her. Here we go again.
I admire you for standing your ground. Maybe this is the last thing you can do for Gord and all those that follow. He is probably up there saying 'you go girl'. I can think of no better way to deal with your anger than to make sure all precautions are in place to hopefully prevent this again. And to let them know they need to better educate themselves on the hundreds of drugs they use.