Have you ever made a medication error- yes, no or almost. - page 4

by Yiggs

10,432 Views | 35 Comments

Nurses, how many of you have ever made a medication error. I don't know if the system will allow us to answer yes - no, almost or never.... Read More


  1. 0
    One time i had two different IV antibiotic bags to hang for two patients in my LTC facility. (I've got about 6mo. experience in nursing so far now) Both were on the same Nafcillin antibiotic, with the same 12gm in the bag continuous 24hr infusion; bags were the same size, etc.... and the name labels were printed VERY poorly- it was incredibly hard to even find the name on the bag. I hung the two bags, only to discover on the following shift, (i hung them at 6pm one night, and about 8am the next morning it was discovered) that they had the wrong bags. No real harm, (None of my med errors have resulted in any actual patient harm) but the dosage was slightly off- the pharmacy screwed up how they mixed one of the bags so they put a different rate on the order for that bag, than the rest- as there were 554mls in that bag, and 503mls in the other one. Both IV bags were 500ml IV bags though, and said 12gm Nafcillin on them in big letters.

    I felt horrible though.

    In part, I feel that my facility promotes med errors by using a paper MAR with lots of little square boxes to sign our initials in on the date we're giving a med... it's hard to immediately see where things are on the sheet, hard to do the triple-checking that is needed too.... plus that it is just challenging to remember to do all of those same checks every time, when one works in LTC with the same residents getting the same meds every day for months.

    Lately I've been finding a number of med/treatment errors that other nurses have left behind though- Lidoderm and fentanyl patches not being replaced/removed when they are supposed to be, and PICC dressings not being changed for two days past their due date!!!.... the PICC dressings really tick me off, because those are central lines- not something to mess around with.
  2. 0
    oh yes! we all make mistakes. Owning up to them is the part that not everyone does. It is difficult to admit it at times but many of them come related to being in a hurry trying to give the best care to many patients each day. I always try to remember that slowing down and thinking about it saves time in the long run..mistakes cost lives!
  3. 0
    I made my fist error recently. The order was Dilaudid PO and I work on a floor where EVERYONE gets dilaudid IV around the clock. So, the PO order was strange and unexpected. I gave the med, (same dose) and then realized it was PO later. I guess I should have reported it, but, I know the pt would not be harmed and it would have cost me months of paperwork and suspicion to report it so I didn't. I don't regret my descision as the pt care is the most importtant thing to consider.
  4. 0
    Quote from Jenni811
    So when i'm doing medications, i am in my ZONE! Our hospital has actually talked about making us wear something when we are doing meds to tell people we cannot be talked to. Instead they thought that was a little excessive and tried the "safe zone" tape. when we are standing in the "safe zone" (a square of red tape infront of the pyxis) we are to not be talked to by anyone! even docs. we are to not answer our work phones.
    At first, I thought this was crazy, but you know what? I think it would help a LOT.

    I love love LOVE my PCTs, but wish they would make sure to at least be around to answer call bells when I'm doing my med pass. I've caught myself about to make an error when I've been interrupted.

    I work 7P-7A and for some reason the techs always take their breaks at 730 when I'm getting my meds together.
  5. 0
    If a nurses tells you they have never made a med error they are lying. Everyone makes med errors. Its scary to think how many errors occur in a hospital setting. I wish management would see the value in following acts.
  6. 0
    acuity


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