First med error

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    Well, I've read a few "med error" posts and I had the same feeling as the few that I read: My heart sank. I work as a SNF charge nurse and had to pass meds for 19 patients in addition to running 7 IVs which included 2 TPN. My med error was with Dilaudid. The MAR and the DEA control record didn't match. I had given the patient her Dilaudid before and the Rx was for 4 Dilaudid tabs (2mg each). Well, the pharmacy provided Dilaudid 4 mg tablets and I gave four 4 mg tabs instead of four 2mg tablets. I basically doubled the patient's dose. Well, I felt so humbled. Not a good feeling. I called the doctor and informed her. I also completed the incident report. The doctor was very nice about it, and said she would most likely be fine because she is chronically asking for pain medication. If fact, she asked for pain medication after I had given her the erroneous dosage. Plus, on another note, the LPN that I work with sleeps during the shift when she is on her "break". I don't feel comfortable with her sleeping but I also do not want to be the whistle blower.

    Will I get reprimanded or fired for my med error? This is the second time(sorry about the title) as I have hung TPN late once before overwhelmed with med pass.
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  4. 8 Comments so far...

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    you did the right thing after you recognized the error. i don't think you will be in trouble. bless your heart for having such integrity.
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    I'm curious as to if the MAR actually said "Dilaudid 4 tabs" because if it did that sounds like an accident just waiting to happen. The MAR should always be listed as "Dilaudid 4mg" so that regardless of the mg of tablets, concentration of med, etc you are still able to quickly deduct the correct dose.
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    Just learn from it, no harm done this time. The whole reason for incident reports are not to punish but to learn from. i have had a med error or two and have never gotten in trouble.

    btw why are you concerned that someone sleeps during their break? i sleep during my break as do most nurses on my shift(night) I am not paid during my break therefore therefore that 30 minutes is 'my time' i can sleep or even leave the facility. I find by sleeping for 30 minutes i am more refreshed and safer for my pts.
    Conqueror+ likes this.
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    Quote from evolvingrn
    Just learn from it, no harm done this time. The whole reason for incident reports are not to punish but to learn from. i have had a med error or two and have never gotten in trouble.

    btw why are you concerned that someone sleeps during their break? i sleep during my break as do most nurses on my shift(night) I am not paid during my break therefore therefore that 30 minutes is 'my time' i can sleep or even leave the facility. I find by sleeping for 30 minutes i am more refreshed and safer for my pts.
    I think the OP was implying her coworker sleeps through the shift in the guise of an "extended break" and may not be giving the patient their pain meds as a result.
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    You did everything right. You recognized your error and took responsibility for it. I know it is hard not to beat yourself up about it. Every nurse has made a med error, and if they say otherwise they are either lying or never realized it! =) Luckily your patient is alright. When a med error is made it is a time for learning, I bet you will never make the same mistake again! *HUGS* Don't dwell on this, you did everything right!
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    Thanks guys. I really appreciate the feedback. @evolving RN: I think if the facility allows, it is OK to sleep for your 30 minute break. The LPN I was talking about though sleeps longer than that(up to an hour) while there is still work to be completed.
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    A chart held about head high and dropped on a hard floor right next to a co-worker resting their eyes has always yielded good results for me. But that's just me, never really liked the idea of me working got by with doing nothing.
    michelle126 likes this.
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    That's good you reported the error. I remember my instructor telling the class "If a nurse says she hasn't made a med error in at least 5 years, she's probably lying". It's a really common problem and I'm glad you went through the right procedures instead of ignoring it.


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