Made a med error and am Furious!!

[kwagner_51]

I made a med error last night that I told the new DON would happen over a MONTH ago!! :angryfire :angryfire

I work 2 Saturdays a month at a ltc.

This is what happened: The unit is Rehab, there were 15 patients 12 were new to me. I got crappy report but figured I could read the charts later. [Which is the way I always learn about my pts.]

It was crazy. I did med pass following the MAR and making sure that every med ordered was the correct one [5 rights]. At 12PM we had a pt go downhill rapidly. He was a full code. We had to get him out of the building fast!! His son and dtr were in the room. I explained that we had to send him to the ER rapidly because of his code status and that we couldn't treat him there.

They transported him to the hospital by ambulance and the ambulance left with red lights and sirens from the parking lot.

I had no lunch, no more than 2 five minute breaks and then at 2:30 I made the error. The IV pump was beeping, because it was almost out of fluid.

I went into the med room and took the bag out of the medical supplies for this patient. I verified that it was hers.[it had her name on it.] I took it down and set it up. I thought that I had saved the next nurse the hassle of having to replace the bag.

I was scheduled to get off at 3PM. Thank goodness I signed my meds when I handed them out instead of waiting until after med pass. We had several things going on at the time.I had given 40mg Lasix IM to a pt. The MAR said that was the med dose and route so I gave it. I did question why I was giving it IM and not IVP.

The Admin. questioned me about the order. She said she had NEVER given Lasix IM. She got the pt's chart out and couldn't find the dr.s order. I showed her the MAR where the order was written but we couldn't verify the order. She finally called the nurse that wrote the order and learned that she hadn't had time to write the actual order in the chart yet. :angryfire

We had one pt with a wound vac on and the Administator and the evening shift nurse were doing her treatment so I stayed on the unit to cover for her and finished passing her meds. I was talking to the ADON about working today when the Nurse came up to me and we went into the nurses station. She told me that I had hung the wrong IV. [On the same pt as the IM Lasix.]

The pt was on D5W 1/2 NS. I hung D5W 1/2 NS with 20meq K+. I told the nurse that I got the IVF from the bag with all the pt's supplies in it. She informed me that the order had been changed 2 days before!!!:angryfire :angryfire

I immediately went to the ADON and told her what I did. I filled out a med error report. When asked what could be done to prevent a repeat. I let them have it. Get rid of old meds or put them someplace way from the other meds. Make sure that ALL old meds are marked D/C or have black lines through them.

This error should NOT have happened. I took complete responsibility for the error I made but I also let them know that I was angry and that policy needs to change.

So what do you think? Did I do the right thing?

Thanks!!

__________________________________

In His Grace,

Karen

Failure is NOT an option!!

[Lisa CCU RN, RN]

Aren't the MARS checked against the doctor's orders before each shift or q 24 h?

[TazziRN, RN]

At our place on the forms we use for both employee injury and med errors, one of the questions is "How could this have been prevented?"

Yes, the OP goofed on not verifying the order, but not all mistakes are 100% one person's fault. There can be other mitigating factors, as in this case.

[Holly27]

This is what happened: The unit is Rehab, there were 15 patients 12 were new to me. I got crappy report but figured I could read the charts later. [Which is the way I always learn about my pts.]

I work nights and when I come in (if time). I verify all meds on the mar to be given after 700pm,(In other words meds that are to be given by me), all orders for the past 3 days,(to make something new wasn't overlooked)and all PRN's. Of course 2 out 3 times a week that doesn't always happen. In that case I only verify the meds the mar SAYS are to be given on my shift.( to make sure they haven't been changed or d/c'd)and all orders for that day(NOW I DO). I pass those and if someone request a PRN med in the middle of my med pass, I go and verify that 1 med for that pt and continue on. After all said and done I go back to my pt's chart, verify all my PRN's and verify that no new orders were written and not documented on the mar by previous shift or at shift change.

And yes I've had one med occurrence so far(I'm sure not my last). And it was on one of those days when pt coded at shift change, I lacked the time to verify the entire mar,Previous shift had a order for K+ stat and again @ 8. Well it was wrote on the chart K+ stat and signed by previous shift but the 8:00 dose wasn't noted on mar or red doted on the chart. No fault but my own still. But I would rather give a dose late then give something that was d/c'd or changed. THAT's also the the reason I NOW look over the orders written for that day,too.Even if short on time. It decreases my chances of late meds again.

Policy says go back 24 hour to verify mar but I go back 3 days at beginning of shift and with new mar at midnight I go all the way back to the orginal order. I guess I'm anal. But I've had a pt in the past that missed a week of a med b/c of the 24 hr policy. So seven days total of 14 shifts, chart was to be checked 14 times. But wasn't caught till I did my normal "check the whole dang chart" routine.

Does your LTC put red dots next to all med orders? Not saying every person does it where I work, but I'd say at least 85% does.

Just my 3 cents.

[morte, LPN, LVN]

no supplies are to be stored sitting on the floor! period.....if the person who accepted the delivery had put them where they belonged this error would not have happened.....again NO supplies on the FLOOR

[kwagner_51]

Aren't the MARS checked against the doctor's orders before each shift or q 24 h?

NO! The MARS are checked 1x a month when we do MAR change over. The LTC was cited for substandard care. Nurses were fired, CNA's quit and the ADMIN was escorted to the door. The DON was fired, rehired, and then quit. The ADON transferred to MDS co-ordinator.

We have almost all new nurses, new CNA's, a new ADMIN, New DON, new ADON, and I talked personally with the ADMIN. She said things were going to change. I tried to explain what I needed from her, but I still don't have enough expereince to really know how to improve the situation.

I was given 2 weeks of oreintation on 2 different units. I work all five units now. This coming Saturday I am working on a unit that has about 28 pts. I have worked this unit one time.

This LTC is a mess, but we are working to improve it. I only work 2 DAYS a month d/t the fact that I have a full time job during the week.

How can I help improve the situation for the pts?

The new orders are NOT dated when they are put on the MAR.

Meds are not ordered, or have been ordered but aren't in the facility.

I had a pt that arrived Friday at 2:30 PM and her meds still weren't there when I left at 5:30 PM on Saturday.

I had to take meds out of the EDK for 2 DIFFERENT pts. The Lasix IM and 2 ATB.

I have no idea why the pts are there. I NEVER get their major diagnosis and absolutely NO history other than when they arrived, what IV meds they are taking, if they are accu cks. etc.

Please give me some usefull advice so that I don't make these mistakes again! I hate giving meds without not knowing why they are getting them.

I asked for a report sheet that lists the Medical Dx, admitting Dx, concerns, if they are brittle diabetics etc. but have yet to get anything like that.

The pt we sent out Saturday had been there for 2 days. If an LPN hadn't been there to do a new admit, the pt would have DIED!!

I didn't know that the way he was acting wasn't normal. I KNOW beyond the shadow of a doubt that he would have coded and died because I DID NOT know what was wrong with him!!

Thanks!

_____________________________________

In His Grace,

Karen RN

Failure is NOT an option!!

[General E. Speaking, RN, RN]

I'm thinking you may need to quit. It sounds very dangerous and unorganized.

[Holly27]

I'm thinking you may need to quit. It sounds very dangerous and unorganized.

I totally agree. I wouldn't risk my licenses working at a place 2 days a month and with what you say is going on. You alone will not be able to solve the med problems or protect yourself or your pts. It's a team effort. You can't be the only catcher on the team. Heck I get frustrated b/c I only work 3 days a week on my unit and come back and a totally different pt census is on the floor! If the nurses won't give you a decent report, it's like starting your shift blind! I hope it works out for you, And yes I would leave that LTC.

PS. Do they keep pt charts on the rounder where you can get to them?

[meownsmile, BSN, RN]

I think you are pretty much answering your own question. Maybe that isnt the place for you to be. Obviously if they lack the reporting and updating skills minimal for you to care for their patients you need to go. It sounds like an unsafe place to be practicing.

Im not excusing the error,, but we all make them at some point. You took the hit and that is what we do, take responsibility for our own actions.

Good luck, dont let this eat at you for to long. Go on and work someplace that has the checks in place to enable everyone to be safe.

[jojotoo, RN]

I also have given Lasix IM, not frequently, but several times.

As far as you hanging the wrong IVF, I know hindsight is 20/20, but just a suggestion for the future: Compare the IVF that you take down to what you are putting up. Is it the same? No? Why not?

And lighten up on yourself. EVERYBODY makes mistakes.:icon_hug:

[SmilingBluEyes]

If there is anything I have learned in nearly 10 years of nursing, it is this:

Med errors often are not simply the cause of ONE person's action or situation alone. They usually have their root in faulty systems, short staffing AND inattention to detail by personnel in departments, in and out of nursing.

I just hope you learned from this and can work to fix the system errors leading to the problem, and take a good look at your own practices, if nothing else, to be sure your part in this is addressed. I have made a few errors in my career, mostly due to being a hurry and NOT accomplishing the 5 rights----one or two were not my fault, alone. I addressed my own shortcomings, but also reported system problems that contributed, as well.

Accountability must be key----ours and everyone's as well. The person receiving the med has little to say or defend him/herself before we make a terrible mistake. Let's just work to fix the problems that cause these errors and try hard not to resort to finger-pointing. That rarely solves much of anything.

[Tweety, BSN, RN]

I think if pointed out a potential problem and then made the error myself I would be furious not only at myself, as I was aware of the problem, but at the system for not acknowledging "potential" problems that were previously noted but not changed.

Good luck.

[CoffeeRTC, BSN, RN]

Aren't the MARS checked against the doctor's orders before each shift or q 24 h?

Not in LTC.