med errors

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Specializes in Brain Injury Rehabilitation.

how many is too many?

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Specializes in Critical Care, Cardiothoracics, VADs.

For what?

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Probably depends on the practice setting and the circumstances of the errors. I think it would be hard to place an absolute limit that applied to all nurses.

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Specializes in Nephrology, Cardiology, ER, ICU.

If people are starting to say something to you, and/or you harm a patient, and/or you have a recurring theme to your med errors, then there is a problem.

At any rate, when you have even one med error, it is very important to sort it out as to what step in the process of administering medications failed and then vow to pay closer attention, fix the step or otherwise correct the error.

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Specializes in Brain Injury Rehabilitation.

I have had three-and they occur during times of stress-I tend to be the one who catches other's errors or potential errors. Each one I have had there was no harm to the pt, I informed the pt and made out incident reports taking full credit. No one has said a word to me and they still put me out to meds over others.

The first one I gave MS Contin instead of MSIR. They were next to each other in the pyxis and I just hit the first 15mg I saw not realizing the differece (I am a new grad).

The second I gave Trazodone 50 instead of Tramadol 50, again, a pyxis errror on my part. I got to TRA saw 50 and grabbed it, again, very stressed that night.

The third was last night-I pulled marinol out of the pyxis and realized later while checking my prns that it was a 10 mg not a 5 mg. Again, I was in a agitated state/rushed.

I just start wondering if med passing is for me.I know where I work many RNS hate passing meds bc of these reasons. It is a HUGE responsiblity. I feel safe but you know, as a perfectionst, I have to second guess myself.I am great in all other aspects of nursing, I just wonder if med passing isn't my best feat. I don't plan on being anLPN forever, maybe another few years. I do get to charge and tech but Mostly meds.

Thanks for the input.

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Specializes in Critical Care, Cardiothoracics, VADs.

Mel, keep asking. Kudos to you for admitting your mistakes; we've all made some. The problem I see with yours is that they are all the same mistake. The good thing is that it's one that is easily fixed.

Regardless of how rushed you are, or how stressed, or how many patients are dragging at your ankles, every SINGLE time you give a medication, CHECK CHECK CHECK CHECK CHECK. Check the patient ID. Check the order. Check the medication in your hand - the name, the dose, the route.

You're lucky that so far none of your patients has been seriously hurt. You're not making *mistakes* - because these are all preventable.

The great thing is now that you are aware of the pattern, you can make sure you never do it again.

To your original question - any error you do not learn from, and adjust your practice to avoid repeats of, is too many.

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Specializes in Trauma ICU, MICU/SICU.

Well said Augigi!

Mel,

I agree with Augigi. Slow down, take a deep breath and remember not only the 5 rights, but the 3 checks.

1. Check the order

2. Check the med when you pull it out.

3. Check the med again before you give it (or put it in patient's cup).

No matter how stressed/rushed you are you must do this.

You are doing great and are admitting your errors, now stop the pattern and make that error a thing of the past.

Remember, we've all made these errors, but we must learn from them to avoid in the future.

Keep up the good work!

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Specializes in Brain Injury Rehabilitation.

thank you for the responses. After bringing this to light to myself, I am going to make a conscious effort to remember to slow down on nights of stress or when I feel over whelmed, for whatever reason. We are getting new med dispense systems which will help. Righ tnow, if you put a patient name in the pyxis, all meds available facility wide will pop up to choose from. The new ones will only have meds available for that patient to choose from. so, errors like the trazodone/tramadol can better be avoided. Plus, you can't get a med out that isn't ordered for that patient unless you put it in due to a new order. So, I can't pull a med out if the pt isn't prescribed it. Does that make sense?? Anyway-thanks again. Working on it daily :)

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