What Goes Wrong Without the 6 Rights

I am blown away by a news story I just saw; several teachers at a school-based H1N1 flu clinic were given INSULIN instead of the flu vaccine they expected.
WHAT.
THE.
F**K???!!
The school system is apparently investigating; no students received insulin thankfully, however the superintendent has sent out a pre-emptive letters to parents.

This is not rocket science; this is not a terrorist attack; this is unlikely faulty packaging. This is human error, and I imagine someone's head will be served on a platter because they failed to follow the rules of engagement of medication administration. These are taught practically Day 1 of nursing school, the "Rule of the 6 Rights": the right drug, the right dose, the right route, the right time, the right patient and the right reason. It is vitally important to get the right DRUG, for Pete's sake read the label.

It is reported that no teachers suffered any lasting damage which is fortunate. I imagine that there will be a few inservices in that school in the wake of this calamity.

I have been a school nurse; it is a tough job as you operate as a stranger in a strange land. The priority is the kids' health, but the job is really what everyone else thinks it should be. School nurses are asked to teach health classes; educate teachers; act as a resource for anyone in the school from the teachers, the custodians, the cafeteria ladies as well as parents. School nurses are mandated to be the immunization police, do health screenings such as hearing, vision, height and weight, scoliosis as well as the follow up and try to get responses back from parents who really could give a crap. Then there are field trips, meds and of course the everyday parade of booboos and broken bones from PE (for you non-school nurses, that's gym, not a pulmonary embolism). School nurses are asked to sit in on, and give commentary in team meetings that involve kids with disabilities, health issues, and anything that impacts learning. I could write a book about it; I did it for almost 10 years.

I feel bad for the school nurse who made this mistake, and that's what it is. Makes ya think. School systems tend to cut and run at the first sign of bad press; it's the modern equivalent of human sacrifice.