First med error - page 2

by LPN9816aj

3,448 Views | 15 Comments

:sniff: Just got notified by my agency that I have to come in and "discuss" a med error that was found by the LTC facility that I was at the night before. I passed 2 halves of med #1 and one half of med #2 and it should have been... Read More


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    I remember when I made my first med error. I have been an LPN for 2 years and worked at my facility for well over a year. We had this lady who had Fentanyl patches. Well her son had brought some in and asked if we could use them. We took them and my dumb butt didn't check the dose and it was higher than the dose she was ordered. I felt soooo bad when my boss talked to me about it. She wasn't upset, but said it happens to all of us. I had to do a report of course. She did pass away, not from the error, but she had chocked on something and had a lot of internal bleeding as a result. She was actually out with her family when it happened. I was so upset when I found out, I loved that woman to death. I hope she is having a wonderful time in Heaven, they are lucky to have her nurse:
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    As a charge I've seen my fair share and done my fair share but I've also heard through the coconut wireless too many times so and so did this and that. I try to follow up but the nurses I worked with at this particular facility were as thick as thieves and protected each other. You tell me how in a facility of 98 residents with 3 nurses passing heavy meds that not one med error occurred in 6 months.

    That's what my boss wanted to know. Well I try to educate them that reporting med errors is not going to get you in trouble but alas that is the one job I gave notice and now pray for the current charge. My boss started an investigation after a resident told the social worker they never received their morning meds ... I can believe it. I couldn't see myself interrogating everyone everyday; seriously. Also I had multiple residents tell me that certain meds weren't given and when I asked the nurses the usual reply was that the resident is senile and forgetful etc... who are you going to believe on and on. I checked this one nurses MAR toward the end of their pass and not one med was marked off as given. They told me they mark off at the end to save time; I still wrote them up.

    As the charge I would have to cover a med cart pass if the nurse called in sick and we couldn't cover the shift. It took me about 4 hours to do the am meds. Then I would look up and it was time to pass the noon meds. What a nightmare! I won't even talk about the treatments. The best I could do was make sure all the diabetics got their shots on time and then hope for the best.

    If you hide it you're doing yourself a disservice. If you hide it nothing is learned the behaviour will continue. So you stop beating yourself up right now. It's part of the learning process; it happens to all nurses ... all. And look at the situation you were in. OMG that's gotta be a nightmare to pass a heavy med pass in an unfamiliar place.

    Tell your boss the truth. Have you ever wondered why you are put there? It's probably because the others have complained and said they won't go there. I would almost say it's suicide to go into a LTC facility to do a heavy med pass as an agency nurse. I give you big kudos for being able to do that. You've cried enough for this one. Pau
    Student04976 likes this.
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    Quote from Whispera
    Everyone makes med errors. Try not to be so hard on yourself! Try to make it a learning experience instead of a self-bashing. You're still the same good nurse you were before you made the error.

    Med errors, by the way, are often (I'd say usually, actually) a result of a system error, such as too many meds/not enough time... When a nurse makes an error, it helps the facility figure out what needs to be done differently to get rid of those system errors. Sometimes they can't do a thing, but if the same error keeps popping up, eventually they'll work on it.

    Again, please don't be so hard on yourself. We've all been there and empathize with you. The important thing is...was the patient harmed? I bet the patient is A-Ok. This too shall pass.

    Sending hugs to you...

    Very well said Whispera!
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    If there is a nurse who hasn't made a med error, I never met her/him in almost 20 yrs as a bedside nurse, I made a few of my own. I worked as an agency nurse full time for almost 5 yrs and for the most part encountered hostility/resentment from the staff nurses from the get go, everyone knows that agency pays more. Occasionally the staff resentment was so blatant that I asked the staffing office to send me elsewhere and they did, no problem. Of course this was before the economic meltdown, demand for agency is not what it once was. Going into a new facility and having to pass meds is one of the most difficult tasks ever! If you are able to find a place that you like, as the staff gets to know you they will warm up. The most important thing is to always be truthful. All of us have made mistakes, the pressure we put on ourselves to be perfect just adds more stress. It's done, let it go and breathe...
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    your response is normal. We all have made mistakes, and we all feel awful about it. We just hope no harm care of it. Think of all the things you have done right. Your ratio is probably 1,000,000 to one. Look forward, be as careful as you can, and be proud you took the responsibility in the first place.
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    My nursing instructor, decades ago told us "You will make mistakes, hopefully they will be small ones." I have made med errors in my career. It always upsets me. I look at each situation and try to figure out what I could have done to prevent it. Sometimes I have been in too much of a hurry. Sometimes it is poor judgement/critical thinking. We have a new medication administration process where I work. Each pt. ID band has a bar code, each medication and IVF has a bar code. You must scan the pt. bracelet and then each med at the bedside, before you give each med. If there is no order for that med, the scanner device will tell you. You also have to enter any waste needed in the device so it prevents overdosage (for example giving a whole tablet instead of a half.) This scanner is reducing our med errors significantly. Changing your process, can make a big difference in safely administering meds. Please don"t beat yourself up about this error. Learn from it and move on.
    Last edit by ICUnurse1985 on Jun 22, '11 : Reason: spelling and adding information


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