Medication error Phenytoin

Nurses New Nurse

Published

I did a stupid stupid thing tonight. I gave a patient 40mg over the prescribed dose. I reported to Nurse in Charge, did an Incident report and contacted medical officer and I have very much learned from my mistake, which has left me feeling like crap. I pretty much didnt obey the 5 Rights. I really pray this hasnt left the patient in serious trouble.

I got home and contacted nightduty staff to advise how shaken up I am and how I wanted annual leave or sick day. I was advised by the nurse in charge of night duty we all make mistakes. We sometimes make an error of giving too much by accident. As long as you learnt from that mistake and make sure not to do it again and always check and recheck.

I did look up the medication on the net as soon as I got home about how much is too much for causing serious effects. They say if its over 2gms of the medication then its serious. I was under that way under. However that does not excuse the fact, that giving the right dose is important.

I am still feeling raw about this situation and may feel like this for a long time. I just pray my patient is ok. Observations will be going on for another couple of hours.

:trout: :uhoh3: :o :bluecry1:

Up Vote Up Vote ×
Specializes in Pediatrics- Adolescents.

Hi Kylie Im a grad RN as well, 3 months in. A couple of weeks ago I gave a double dose of methylpred IV. As Im sure youre feeling now, my heart stopped and I felt sick for days afterwards. I went back to work the next day, wanted to see how my patient was going, then took the next day as a sick day because I was then due for days off.

Reflect on it, but then you need to move on and push it out of your head so you can go back to work.

Everyone will tell you éveryone makes a medication error, just as long as you've learnt from it'and it is true.

Chin up Kylie, I know how you are feeling and I'm sure once you get your confidence back you will be able to continue learning to be a great nurse!

Up Vote Up Vote ×

The patient'll be fine. Dilantin'll sedate him a little maybe, but he'll be fine.

Go into Geriatric and look for a thread entitled "I'm a Medications Menace." I started it. You'll get a lot of great tips on safe administration.

Everyuone makes med errors. The skill is really to keep them to a minimum as complete elimination is impossible.

Up Vote Up Vote ×

Hello K.. I wanted to say that no one really tells us how busy and crazy being a staff nurse is like. You are not the only one who has done this. I give you a lot of credit because I knew many nurses new and old who did med errors and never filed a incident report. I had a very hard time with that because I could never do that.

But I too had a med error as a new GN. I worked 6 days straight one week and had the same pts over and over again. Which was nice b/c I got comfortable with them. I will never forget this lady. I was told she was a trouble maker. She took ativan pushes a lot. Every evening she had to have one and if you weren't there in her room she called for you. So I was running mad with new admissions and blood transfusions that she was yelling for her ativan. I ran to the med room and gave it to her. Knowing she always got it in the evening. OFcourse when I went to check my meds I saw that the docs had dc the med. My heart stopped. I was so comfortable that she always took it that didn't check b/c I was running crazy. I immediately talked with the nurse in charged but luckily she was use to taking it every evening that she was ok but still. The fact that we get so busy and forget to check the meds 1st. THis had never ever happened to me again. I don't care how crazy I got I stoped and checked med and the name badge on the pt that is very important.

Up Vote Up Vote ×

Thank you for your replies and supportive words.

I have learned from this and it will be on my conscience for when I dispense medications.

Up Vote Up Vote ×
Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.

Owning up to the mistake and learning from it is 50% of it. Forgiving yourself and moving on is the other 50% and the hardest part.

Up Vote Up Vote ×

Hey,

I echo what everyone else has said. It DOES feel really lousy to make that mistake. If it makes you feel any better, I give a lot of Dilantin to patients and I'm SURE that a one-time extra 40mg will not make a difference to their well-being. Best wishes.

Up Vote Up Vote ×

The nurse in charge of the shift last night is lovely. However she was very very disapointed in me. I dont blame her, I am dissapointed with myself. The only concern is facing the Nurse Unit Manager (as I dont want to) and he may question me and question me where I really dont know the answer as to why I did what I did. I can only let him know I have learnt to be more alert when giving medications and that I promise I wont make the same mistake twice. :nono:

I was wondering Vrhodes as to what happen with you when you made your drug error mistake? Did you get support from the team?

I am going to face the music tomorrow with my tail between my legs. The feeling has to wear off soon????????:uhoh21:

Up Vote Up Vote ×

Hey, hey, hey! Charge nurse last night, whom you described as a lovely person who told you that stuff happens, isn't disappointed in you. YOU are disappointed with yourself.

As Tweety said, forgive yourself, learn, and move on.

Up Vote Up Vote ×
+ Add a Comment