Worst Medication Error of my life

Specialties Cardiac

Published

Well, I have worked as a Progressive Care Nurse Cardiology since graduating in 2010. My patient started to have chest pain, nitro sublingual was ORDERED and given. The chest pain was still unrelieved, 2 mg morphine iv ORDERED. Morphine was not available after waiting 5 minutes. The physician looking at me stating he needs his morphine. I webt to the Pyxis to find no morphine, I then override to obtain the morphine immediately. To my surprise I selected VERSED and administered in errir 2 mg At the time iI am also trainin a new graduate nurse. I felt so...bad. The physician notified on the floor, patient was fine (Thank God). We do not give consious sedation medication on our unit. Why was I able to pull this medication? Regardless, I am responsible. What will I be faced with during a peer review at my hospital?

Specializes in orthopedic/trauma, Informatics, diabetes.

We can only override certain medications on our pyxis and we don't even stock Versed. We have many a resident ask for it to do bedside procedures, but t is not allowed on our unit. The nurses know it but the residents don't always. I suppose the code cart has stuff, but thank goodness, I have not had a code, yet.

I would suggest getting out of your pyxis. It as a good lesson for you and the new grad.

Specializes in ED, ICU, PSYCH, PP, CEN.

There is not a nurse ever, that hasn't made a med error. Of all the things we do to a patient, giving meds is the one we must always take time and do our 5s. You are a fairly new nurse, and aren't comfortable yet with the mind set that giving safe pt care is way more important than an impatient doctor. It will come.

And yes, your student was present for a very valuable lesson. God works in mysterious ways.

I, have made 2 really big med errors (no harm) but I learned to triple check anything I give no matter what.

Hugs to you

Specializes in Adult Internal Medicine.

We have all made errors.

The patient is ok. You have taken responsibility for your part of it. But nothing helps you sleep better at night except for time. We always remember the patients we inadvertently hurt but we forget all those we help. You can't change the past but you can impact the future.

Be honest in your peer review. As you can see from posts here with similar errors, there is room for systems improvement to avoid this in the future.

Big hug out to you. When I used to do QI with med errors the single greatest common factor was nurses not reading.

You poor thing. :(

It's a horrible feeling.

I am glad the patient is OK, and now, take of you.

Specializes in ICU.

I once pulled a meperidine ptca vs. A morphine PCA syringe from the Pyxis. And put it In the pump. When I did that, the particular med for the patient was loaded in. You could take out anything for anyone. I felt awful.

You saw midazolam instead of morphine. It's unfortunately a human error to make, especially in a pressing situation. I'm glad you patient was fine and sees you as human, great nurse

Specializes in OB (with a history of cardiac).

I found that the one time I had a student with me, I felt totally discombobulated. I forgot stuff, I fumbled with stuff- and I work on an OB floor so we're not passing a lot of hard core stuff too often. I don't know, maybe you've oriented people before but as another poster said, you've shown your orientee that even experienced nurses are human and make errors. You're showing the right attitude- you're not being defensive or denying it. Sounds like you had your peer-review and it went fine. I don't know, I look at passing meds like driving. I don't care how hard you're tailing me- I'm going to go the speed limit on the freeway when it's snowing. I'd rather make you irked than die. So- what I mean is yes, sometimes time is of the essence with getting a medication, but always remember that no matter how hard a doctor taps his/her toe and taps their watch, you're going to keep that patient from further damage. The docs seem to have so many safety nets and get out of jail free cards whereas nurses don't.

Specializes in Medical-Surgical, Telemetry/ICU Stepdown.

If the employer had a bedside medication scanning system (barcode)-I don't know if they do-the chances of giving a medication that's not on the med profile are very low to none, even if you pull the wrong med. We have such a system and it's very effective, easy to use and reliable. It makes my life as somebody who dispenses medications so much easier.

Bedside barcode scanning spoiled me-I will never again work for a company that doesn't have this kind of system because without it the risk of med errors increases exponentially.

I think it should be a standard question during a job interview-"do you have bedside barcode scanning?". It would definitely influence my decision to accept a hospital position or not...

If the employer had a bedside medication scanning system (barcode)-I don't know if they do-the chances of giving a medication that's not on the med profile are very low to none even if you pull the wrong med. We have such a system and it's very effective, easy to use and reliable. It makes my life as somebody who dispenses medications so much easier. Bedside barcode scanning spoiled me-I will never again work for a company that doesn't have this kind of system because without it the risk of med errors increases exponentially. I think it should be a standard question during a job interview-"do you have bedside barcode scanning?". It would definitely influence my decision to accept a hospital position or not...[/quote']

But she said the morphine wasn't available after 5 minutes....so I know in our scanning system, it wouldn't have shown up. It doesn't show up until pharmacy approves it so if you are overriding in the Pyxis or pulling out emergency drugs, the scanning is useless.

I do like it for normally ordered meds though!

Specializes in Tele, Med-Surg, MICU.

So if asked, what med would you give to reverse the Versed? What s/s would you be looking for that the patient is in trouble?

The med error, in the scheme of things, is not a big deal - minor, reversible, and most importantly, you owned up to it. I think that taking responsibility for your own errors is key. And you learn from it, and change your practice.

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