I made med error, what now?

Nurses General Nursing

Published

I am a new nurse, and I made my first med error. I gave a pt IGg who wasn't supposed to get it. I did my five rights. I checked the med against my mar. I confirmed right dose right pt right route right time. It was all good. I even called pharmacy!!! I had no idea how to give or titrate this med. I watched my pt carefully. I made sure her pressures etc were all wnl. The problem was that pharmacy had put the med in the wrong patients MAR!!!! the reason I made the error was because I did not look for the original order in the chart. Had I done my chart check like I was supposed to I would have caught it. I didn't. I came in the next day and was told what I had done. fortunately the patient is fine, and she had no ill effects from the drug. But it could have killed her. I could have walked into work and found out that someone was dead because of me. how do you cope with that? how can I go in and not have a panic attack? I am not getting fired although i can't say i would blame them. I am absolutely devastated( i cried nearly all shift) and now I have to go to a root cause multidisciplinary review thing and explain why I am an idiot. how do I explain that?!!! well thanks for listening!!

Specializes in RN, BSN, CHDN.

I am sorry this happened, but you would be shocked if you knew how often mistakes occur. I was giving somebody an IV drug which came up from pharmacy it was one of those kind which has the drug in a little bottle and you break the connection between the drug and the fluid. The yellow label on the bag of saline had the right drug, the correct strength, the right patient, but the bottle with the drug in it had the wrong strength it contained double the prescribed dose!! Now when I pointed this out to the CN the other staff said oh we never check the bottle we just read the label on the bad of saline!!!! Sure enought the drug hung in the pt's room from the previous infusion was the wrong strength on the drug bottle.

So who's mistake?? Both Pharmacy and the staff member for trusting the pharmacy- this is why I like to make up my own AB's because if I am infusing it into a pt I like to know I am infusing the right drug, the correct strength. So if I do make a mistake it is my mistake not the mistake of others, that I will be in trouble for.

Specializes in Occ health, Med/surg, ER.

state the facts and keep your head up.i know how it is on a busy med surg unit, esp on monday morning, orders are changing q 15min! it could happen to any nurse that is overwhelmed. take the best from it. always remember, the doctors orders are your bible! also, if you cant read the doc's orders, ask another nurse first....but if you are not sure because the doc writes like a preschooler, then you call him on it!!!! i wont tolerate doc's orders that i cant read......p*sses me off. like i dont have enough to worry about without having to decipher crappy handwriting.....:uhoh3:

Specializes in Med/Surg, ER and ICU!!!.

While in school, our instructor told us that EVERY SINGLE NURSE will make a med error. Either they are to stupid to notice it or they are to ignorant to admit it.

I have always been taught to check orders at the beginning of shift. I get report, make a quick round and then sit down for 45 minutes to check charts. If the chart is not checked, the person doesnt get any of their meds until it is. Throughout the day, if their is a new med ordered, I go to the chart and verify it first. No other way is that pt receiving that med first!

Fortunately, every nurse on my floor does chart checks, but I can see were on a different floor a nurse might receive ridicule for doing this, but you have to.

Yes, this WOULD HAVE BEEN a pharmacy write up if it had been caught before the med was administered, but because it was administered it is a nursing med error.

OP, you learned from you mistake, hold you head up high and know you are not the first person to make this same mistake, and you wont be the last. The board you will be going in front of has heard it before and will hear it again. Be honest and say that you have learned from this mistake.

Good luck and keep us posted. One can tell you are a good nurse. You are upset about this and want to make it right. If you werent a good nurse you wouldnt be here. Again, good luck!

texas

Have to kinda agree with CRitter Lover.

In LTC, we don't do chart checks like you would in the hospitals, so things wouldn't be found like that. When I see a new drug for a pt, I always ask "why?" In fact, you should be aware of what the drugs are for and whey the pt is taking them. I'll bet that is why you may have had that nagging feeling?

Don't beat yourself up. You are now part of a club that no one really wants to join.

Specializes in progressive care.

there was a supporting diagnoses on the med, guillien barre was the indication on the med. I didn't recieve this info in report but i didn't look it up. the pt had a history a mile long and it is not uncommon for things to slip through the cracks. I have learned quite a few valuable lessons from this incident. I forgot one of the basic questions. why is the pt getting this med? had I looked into this issue further I would have caught it. I keep going over and over this in my mind. the order was written on the previous nurses shift and she should have checked it off. normal procedure at my hospital is to do a 12hr chart check with the oncoming nurse and check it off the computer. the nurse before me showed me the chart and just told me what she had done and that she had checked them off. I signed off with her. First mistake.lesson: never sign off on anything you didn't do yourself. i knew this but did it anyway, there were calllights going off and i had a hundred other things on my mind. second mistake: med had to be requested from pharmacy, I had never given it and I didn't know what it was for. asked pharmacy how to give it they told me and told me what to watch for... I didn't look it up my self. third mistake: I didn't verify original order... biggest one of all I think. There was actualy more than one error on my part as I see it. I had all of these opportunities to discover the error and I didn't. this scares me to death. I don't believe I will ever make this or a similar mistake again. But it happened so easily the first time, it could happen again. I don't want to kill anyone, my god, I came into nursing to help people not hurt them. does anyone know if this lady could die from this later? is she out of the woods? they sent her to a less acute floor because she was more stable but could this affect her later? the docs wouldn't have sent her to med surg if she could still have ill effects from it would they???

so I am obviously having a hard time with this, I apologize for harping on it. people keep telling me that i have learned a valuable lesson and I have. I pray to God that it stays with me. Nursing is terrifying!!! no one ever told me how scary it really is. they tell you you are responsible for people lives. but i don't think it really hits home til you nearly take one. it is weighing really heavily on me. How have others dealt with this kind of thing? if you have n=made an error how did you get over it?

Excellent take home points!

Eventually you do just get over it - it's all a part of learning how to leave work at work. It is stressful enough to be a nurse - take care of YOU too! :) Remember, no one is perfect and we have all done things wrong....it's just part of being human. You learned from it.....that's all you can do for now.

I'm sorry this horrible incident occurred to you. BUT we are human. It's happened to EVERY nurse at some point in her career! Learn from it. Realize that you DID NOT kill anyone (even though that could have been the case as you pointed out). Think about how many times this happens to other nurses like yourself. Be proactive in fixing the problem. For example:

At our hospital we have computerized charting (to include the MD's entering in computerized orders). We also have a computerized method for our medications. When an admission comes in, the admitting nurse verifies all of the MD's orders/meds. We verify those orders by making sure that pharmD's have entered what the MD ordered. We have a "home screen" in the nurse's station that tells us when new orders arrive (via RT, MD, Diabetes NP, etc). We verify those PRN and again verify that what the MD ordered is what the pharmD typed in.On our system, you also scan the bracelet, so you know it's the right pt.

From hearing what a lot of the other posters have said, most people are still using the MAR's, paper, which can be very tricky and a lot easier to make a med error.

Try not to beat yourself up too much.

GL!

I'm sorry this horrible incident occurred to you. BUT we are human. It's happened to EVERY nurse at some point in her career! Learn from it. Realize that you DID NOT kill anyone (even though that could have been the case as you pointed out). Think about how many times this happens to other nurses like yourself. Be proactive in fixing the problem. For example:

At our hospital we have computerized charting (to include the MD's entering in computerized orders). We also have a computerized method for our medications. When an admission comes in, the admitting nurse verifies all of the MD's orders/meds. We verify those orders by making sure that pharmD's have entered what the MD ordered. We have a "home screen" in the nurse's station that tells us when new orders arrive (via RT, MD, Diabetes NP, etc). We verify those PRN and again verify that what the MD ordered is what the pharmD typed in.On our system, you also scan the bracelet, so you know it's the right pt.

From hearing what a lot of the other posters have said, most people are still using the MAR's, paper, which can be very tricky and a lot easier to make a med error.

Try not to beat yourself up too much.

GL!

Specializes in ICU.

Thomask,

IGg metabolizes to half-life in 27-36 days with a clearance rate between 2.988 and 3.648 mg/kg/day

http://www.springerlink.com/content/h35u2t521451814k/

the stupid part of the whole thing is that I had a little nagging voice in my head that said 'hey wait a minute'... I was so busy and overwhelmed with my tasks that had to be done that i didn't listen. I have learned alot from thiswhole experience. I know that I will never enter a shift without doing a thourough chart check. I will never trust other peoples checks and I will remember that the dr's would much prefer that a med be given three hours late than for me to give the wrong one. my manager said I didn't have to go to this meeting but that it would look good if I did. I don't think I can get through it without bawling my eyes out. he said I could write something that says what happened. luckily my hospital is very supportive of their staff. we had a few very infamous errors within our hospital system that resulted in a few pt deaths. again it was pharmacy that started the error. they were extremely supportive of the nurses and they did not get fired. they were offered other positions if they wanted them or they could keep the same ones. the meeting i think is just to find out why it happened and how they can stop it from happening a again. they need to know how it got through the checks. How do you say your an idiot without making yourself look bad?

try to forgive yourself- you will eventually and remember your patient wasn't harmed!

I made 2 med errors in my career - one was because I didn't understand the pump equipment (gave too fast) and I was too embarressed to ask someone (new RN) NEVER did that again - I will never use equipment I don't know/understand.

The other was I incorrectly read an order and thought it was to be given that day (it was a weekly injection) and I called pharmacy and had them send it (it wasn't due for 5 days) - and they obliged me without checking either and I gave it and then went to document and it wasn't there to document for "that day". I reported it, MD aware etc etc...no harm to patient....but I have to say I learned very valuable lessons from those mistakes and I triple check my orders/meds etc.

The other thing I do is I always make sure the drug "makes sense" for the patient and their dx. Thankfully most all of our MDs input orders into a computer now so NO MORE reading horrible handwriting!

The old adage that we learn from our mistakes is very true - sometimes they are our greatest lessons!

forgive yourself

While in school, our instructor told us that EVERY SINGLE NURSE will make a med error. Either they are to stupid to notice it or they are to ignorant to admit it.

I have always been taught to check orders at the beginning of shift. I get report, make a quick round and then sit down for 45 minutes to check charts. If the chart is not checked, the person doesnt get any of their meds until it is. Throughout the day, if their is a new med ordered, I go to the chart and verify it first. No other way is that pt receiving that med first!

Fortunately, every nurse on my floor does chart checks, but I can see were on a different floor a nurse might receive ridicule for doing this, but you have to.

Yes, this WOULD HAVE BEEN a pharmacy write up if it had been caught before the med was administered, but because it was administered it is a nursing med error.

OP, you learned from you mistake, hold you head up high and know you are not the first person to make this same mistake, and you wont be the last. The board you will be going in front of has heard it before and will hear it again. Be honest and say that you have learned from this mistake.

Good luck and keep us posted. One can tell you are a good nurse. You are upset about this and want to make it right. If you werent a good nurse you wouldnt be here. Again, good luck!

texas

I check my orders every day before I start working my shift too - I don't trust "report" completely and we are responsible to know the orders for our patients.

Good advice - we all learn from mistakes - even ones we didn't do ourselves...it keeps us diligent!

My very first med error was made before I'd even taken Boards... It was terrifying, but to this day, I can tell you the concentration of haldol injection--- it's burned into my brain ;)

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