Medication error... ALMOST.

  1. I'm a new nurse, 3 months and counting. This happened a week ago. I had this 60 y/o DM male patient who had a cellulitis on the left lower extremity. I assisted the doctor in doing I&D inside the room. Pus. Lots of it.

    (I heard later that the patient's wife knows the doc's mother personally so they agreed to do I&D inside the room to not add up the financial burden of going to OR for such minor surgery.)

    Afterwards, she ordered to give ATS (anti-tetanus serum) 3000 units IM after negative skin test and TeAna 0.5cc IM.

    So okay, I explained to the patient the new meds I'll be giving. I told him I'll have to inject those meds on his arms. Then I did a skin test for ATS and injected the TeAna on his left arm.

    After 30minutes, I went back to check the skin test.. and called the ROD. It was negative. I had the ROD signed the chart.

    Then I went back to the patient. There was a side drip antibiotic on the main line so I removed it first. Then the next thing I remembered, I inserted the syringe with the ATS on the main line tube!!! OH MY GOD!!!! I don't know what happened but I just realized that I've already inserted it there!! Good heavens!!

    I was so relieved that something inside me stopped me from pushing the syringe... I was ONE PUSH away and I'll have my first ever med error as RN!!! :smackingf

    I immediately withdrew the syringe from the tube.. and said to the patient that I'll just go back to get an alcohol swab from the station.

    I went back to the room and asked for the patient's name again, and told him I have to inject the med on his right arm.

    He said kindly, "Yeah. I was wondering why you put it in the tube? I thought I heard you telling me I'll have both meds injected on my arms."

    All I replied was "Oh." Then told him to inhale because I'm about to inject the med. I said "thank you, sir" when I was about to leave the room.


    I never admitted to him that I almost made a mistake. I don't want to lose any patient's confidence in me.

    He was discharged a day after.
  2. 5 Comments

  3. by   fiveofpeep
    thanks for reminding us all of the huge importance of not only remembering to check the med and the pt, but also of checking the route
  4. by   HeartRN_09
    Well the good thing is you caught it. I've made a few minor med errors myself. It's just something that will happen, you can count on it. Especially with meds that you don't give routinely. I pushed something IV once that was ordered IM. It can be given both ways (Thank God!). I now check all my meds 3 times for drug name, dose, and route before giving it to the pt. Haven't had an issue since I started doing that. lol.
  5. by   fiery_ai
    My first, and hopefully the last, med error happened when I was a nursing student. I was in my 3rd year then, assigned in the ward.

    I gave a whole tablet to a patient.. I forgot what it was. But it should have been cut in half.

    I only realized my mistake when I was about to throw the med foil.. I read it and read the medication ticket, and realized that I gave twice the dose of the ordered med.

    I immediately told my clinical instructor about the incident. Afterwards, we reviewed the MIMS for any adverse effects of the overdosage of the drug.

    I continued to monitor the patient the rest of my shift. No adverse reactions, thank God!! Good thing, it was only a tablet.. still, you can just imagine my fear as a student.

    From then on, I always check the stock dose of any ampule, med foil, vial.. And so far, I'm doing well.. except for this one. Another medication error... almost!!!! Lol.

    Seriously, I believe that one really learns from past mistakes. I'm praying that I won't make any medication error in the future.
  6. by   Nire83
    Phew! Good thing you had a nursing angel on your shoulder! I can totally picture that happening and that wave of shock coming through you as you were JUST about to push it. Good instincts!
  7. by   mustlovepoodles
    Good catch~ Everyone makes a med mistake sooner or later. You try your best to always do the 5 rights, but sometime something will slip by you and a mistake is made. We always hope it will be fairly minor. But to think you will go through your entire career mistake-less? That's a mistake.