First Med Error

  1. I am so upset!! I made my first med error after 2 years of nursing. I am very, very diligent, I always double check my order, I always check allergies, I made a promise to myself as a student that I would never once get lazy with my med passing process. Well, I started working PRN at a psych hospital 5 months ago for some extra cash and started using a MAR for the first time. Well, on the children's unit it is hand written and the Dr. changes the orders every single day, so you end up with 20 kids, each kid as 6-10 pages of very sloppy MAR with everything crossed out, highlighted, switched around, you get my drift. Well, I always scroll down looking for my 20 meds to give and I skipped over a 20 and failed to give a pt. a dose of Adderall. This 20 was written on the wrong line, circled for some reason, and had the drug name written ON TOP of the 20. The thing that gets me, is I checked this MAR three times, my usual two times and then once again when the child said "where's my blue pill" I checked the MAR again, (missing this 20 AGAIN) then looked at all his meds to see if there was even a blue pill--well they are in the narc's box of course, so I didn't see it. I have never given Adderall at night before. Anyway, I don't want to sound like I am trying to place the blame on the MAR, but I am a bit of perfectionist and I take pride in my work, and I can't help but feel like maybe this is a dangerous place to work. Sure this time my mistake caused no harm, but it makes me so nervous that this sloppy MAR process has so much room for error, what if next time it is a big mistake? I am used to using the Omnicell in the ER one chart, one order right in front of me, not alot of room for error. Maybe I can convince them to adopt a better system, he, yeah right......

    Would you quit this job?

    Perhaps I am over-reacting--I am pregnant and a bit, ummm, psychotic!
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  2. 9 Comments

  3. by   nurseofalltrades
    Mistakes happen. Whether people believe it or not, no one isperfect. Don't be so hard on yourself. I wouldnt quit a job every time I made a mistake. It will make you more attentive next time!
  4. by   joaha0826
    I don't think I would quit, yet. This looks like an excellent opportunity to initiate a change that would benefit the entire facility. As patient advocates, nurses need to identify issues that have the potential for compromising patient safety and work to correct these issues. Ask your co-workers if they are satisfied with the MARs, you might find most of them would support you in trying to fix a dangerous situation.
  5. by   kate1114
    Quote from joaha0826
    I don't think I would quit, yet. This looks like an excellent opportunity to initiate a change that would benefit the entire facility. As patient advocates, nurses need to identify issues that have the potential for compromising patient safety and work to correct these issues. Ask your co-workers if they are satisfied with the MARs, you might find most of them would support you in trying to fix a dangerous situation.
    I completely agree. Also, to the OP, I don't think it looked like you were trying to "make excuses" for your med error, just showing that you had really thought this through and pinpointed where the system went down. I would discuss the issue with the dangerous MARs and see what can be put into place. It looks like a rather dangerous idea. It's been years since I've dealt with a handwritten MAR - I've grown accustomed to computerized MARS or charting meds on computer. That way the meds also go through a verification process with pharmacy (since they enter the orders into the computer system and we double check the entered orders for accuracy).

    Good luck!
  6. by   nservice
    I agree with joaha. Accept your mistake, but definitely talk to risk management about this problem. I would make a copy of the messy MAR to send along with my incident report. Heck I would copy every messy MAR I come across and start a campaign to improve things. Do your nurses attend any type of quality council meetings. This might be a good thing to try and start.

    Remember, you're not trying to cause trouble when you initiate these kinds of changes...Your trying to improve patient care and safety!
  7. by   miko014
    We used to use handwritten MARS up until about a year ago, and I don't miss them at all! It's a lot nicer to have the computer double check things with you!

    I can see why you are upset - it's a system that could obviously use improvement. It seems like you are angry because it never should have happened, and if there is a way to fix it, you should go for it! Especially for the safety of the kiddos!
  8. by   rngreenhorn
    Why was the kid getting adderall at night? Was it a actually ordered that way?

    I've never worked in a peds psych unit... I'm completely suprised that kids have 6-10 pages of meds... wow.

    Sounds like you are doing a good job with the lousy system. I probably would have made a med error the first day. From what you've described, you are being way to hard of yourself.
  9. by   AfloydRN
    To be honest it does happen to everyone at some point. Did any harm come to anyone because of it? I would talk w/ the manager about electronic MAR's or some standardization so it clears up other potential errors.
  10. by   lauralassie
    Every nurse is going to make mistakes. If your worried about the saftey of your facility vs, your nursing license I may think about quiting, but that has to be up to you. I wouldn't worry so much about the mistake. It's like I tell every new grad I orient , "if a nurse tells you they've been a nurse for a long time and has never made a mistake, either they are lying or they're too studpid to realize it".
  11. by   chuck1234
    Nobody is perfect!
    We all learn from mistake!
    We all make mistake...well...unintentionally!
    Don't quit! Don't give up!
    Life goes on!
    Life is short! Be happy!

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