1. Lucas, Anna Maria BSN, RN

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Once again you've hit on a hot topic for me ("An Error by Any Other Name,"Original Research, June). I was once a party to a major medication error that involved a three-year-old. I tried to avert the error by bringing the excessive dose of dexamethasone (10 times what was needed) to the physician's attention, but he just shrugged me off. I then administered the medication with help from the physician and a medical assistant. One shot had to be given in each thigh, and the child had to be held down, which only added to my distress afterward. I felt like the Marquis de Sade. But I was new at my job and didn't want to make waves.


On the following Monday, I brought it to the physician's attention again. He'd realized what happened but hadn't yet notified the child's parents. I insisted he call them immediately. The administration was unhappy that I had forced the physician to acknowledge his mistake, and I was fired on trumped-up charges. I was going to sue for wrongful discharge, but I complained to the state licensing board instead. I was told that if it had been any other drug the doctor would have been prosecuted for malpractice (I found out later that he ordered not only the wrong dose, but the wrong drug), but since the drug was dexamethasone, which has a wide range of dosages, he was sent a letter of concern.


Doctors make mistakes. They're not saints. Neither are pharmacists, respiratory therapists, or radiologists. We all need to be vigilant and take responsibility for an error when we are in the wrong.


The fact that only 8% of physicians see nurses as part of the decision-making team makes me more determined to succeed in my nurse-practitioner studies. Why do nurses let doctors pick on them? My tale says it all-we're likely to get fired if we challenge them.


Anna Maria Lucas, BSN, RN


Owings Mills, MD