Medical errors

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Night shift never seems to "remember" pre-procedure checklists,consents or med recs. This is a HUGE problem since procedures often start shortly after shift change. (Of course they are not there to here the special procedures nurses making sarcastic remarks or the docs go ballistic!) If I know the day before I take care of it, since it ultimately falls back on me (according to the director).

I've seen several instances of patients being ordered medications that were on their allergy list. I've seen patients with allergies who were not wearing an allergy band. I've seen many patients with long lists of medication allergies when most of them were actually adverse reactions (like nausea) rather than true allergies.

most of the "common" errors I've seen come from either new grads who weren't paying attention and doing their five rights (i.e., a new grad who gave an IV nexium gtt which was to go over 24 hours as a bolus over 1 hour because she assumed that's what was ordered without verifying OR reading the bag) or from experienced nurses who just "assumed" and weren't paying attention (i.e., the same abx for two different pts due at the same time given to the other patient).

Hi, -
Good subject to look into. I have a couple of stories about nurses making medication errors, if that's the sort of error you are looking for. The first is a med error discovered by the finance department's nurse auditors. The RN on the floor had apparently been trying to administer a dose of a q6H antibiotic along with the morning med pass (0800).She got an error message stating that the administration was too early. She overrode the warning and gave the medication anyway, adding a note to the MAR which read, "This damned computer doesn't want me to give this medication." The antibiotic was on a 05-11-17-23 schedule, so she was determined to give the medication either three hours early or three hours late. She didn't have time to check the medication schedule because she had to have time to write a note explaining that the damned computer was causing the entire problem. It never once occurred to her that she should listen to the alert and figure out what it meant. There was just no way that error was caused by anything but the damned computer. I don't know if stories of this nature are what you are looking for, but if this one works for your project, I'll tell you some more. I'm the Informatics nurse at my hospital, and believe me, the war between technology and nursing is not over.

Many of the medical errors that I have encountered over the years has to do with nurses not clarifying a doctors order. I don't know what it is precisely, but some nurses do not want to "bother" the doctor and just assume they know what and how a drug should be given. In my experience, I haven't seen too many new nurses make mistakes because they tend to be a bit more meticulous with checking orders and reading the MAR. Mistakes get made when orders suddenly change. A med that you are used to giving a patient three times a day may get changed on day shift to BID or QID...however, the next shift "knows" the patient and gives the med as she/he remembers it to be given. I've seen a lot of that.

And yes, I am guilty of it myself.

I work in long term care and one error I see new nurses making is to "help" a patient by administering something like aspercreme or Ben Gay or something when there is not an MD order for it. Doesn't matter how it got there, we can't give it without an order.

dian

I am a renal nurse that works on a 43bed unit with an agency run dialysis room. IV Antibiotics are ordered post HD. They are supposed to be given on rinse back. Therefore, the HD RN is supposed to give the medication. On our EMAR, it is scheduled with no time attached and the route is HD. Through lack of communication, we had a yong septic patient go 7 days without the meds because the HD RN thought the floor nurse was giving it and the floor nurse thought the HD RN was giving it.........this young man almost died.

There is no accountability here.