Made a med error and am Furious!!

  1. 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!!
    Last edit by kwagner_51 on Dec 10, '06
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  2. 24 Comments

  3. by   JoycMarr
    Yes, your error(s) could have been prevented, by YOU! Why are you putting blame on others for your mistake? You did not follow the 5 rights did you? Lesson learned, never give a patient medication without doing a chart check first, and NEVER hang an IV bag without LOOKING at the contents.
  4. by   SakredStrega
    I believe I have to agree with JoycMarr.
  5. by   Spidey's mom
    Hi Karen.

    I've given Lasix IM.

    As to your concerns, YES something needs to be done about old meds still being available.

    However, ultimately with the 5 rights of administration, this should not have happened. It sounds like there are lots of things wrong on your unit - the rushing pace, no time to check your MARS and the charts.

    You took responsibility - good for you. But there are things that need to be changed.

    Good luck!

    steph
  6. by   VivaLasViejas
    None of us walks on water. Who among us (that have practiced for any length of time) can honestly say we have NEVER made a mistake?

    I think most, if not all of us, can relate to the OP's frustration and anger, with herself as well as the system that makes it all too easy to commit medication errors. This is not the place for judging or condemning; instead, let us offer our support, instead of attacking her and putting her on the defensive, so that she can learn from the experience and do better from now on. Steph is right---it is NOT just this nurse's fault; there are changes that need to be made in the facility in order to prevent future errors of this sort.

    Just my two pence worth.
    Last edit by VivaLasViejas on Dec 10, '06
  7. by   kwagner_51
    I already took responsibility for my mistakes!! I was furious BECAUSE the new IVF was nowhere near her supplies. The bag with the right IVF was on the floor inside the nurse's station between the counter and a cabinet.

    Yes I made the mistake of not checking the IVF but to PREVENT it from happening again, to me or someone else, POLICY needs to be changed. Why was the d/c'ed fluid still in the bag with the supplies? Why wasn't it marked in black to alert those of us who don't work every day? Why wasn't it thrown away?

    THANK GOD the pt wasn't injured by my mistake. I almost threw up when I realized what I had done.

    The order for the IM lasix was legit. That wasn't a med error. Thank goodness.
  8. by   GingerSue
    several important points in this

    5 rights - always, no matter what is available, these have to be checked

    good idea to remove anything this is no longer being used - to prevent confusion

    this is one of the learning situations
  9. by   indigo girl
    Quote from stevielynn
    Hi Karen.

    I've given Lasix IM.

    As to your concerns, YES something needs to be done about old meds still being available.

    However, ultimately with the 5 rights of administration, this should not have happened. It sounds like there are lots of things wrong on your unit - the rushing pace, no time to check your MARS and the charts.

    You took responsibility - good for you. But there are things that need to be changed.

    Good luck!

    steph
    I have given lasix IM often and I agree with the rest of Steph's post also.
  10. by   clee1
    1) Mistakes happen.

    2) P & P is NEVER completely foolproof.

    3) I have given Lasix IM before.

    4) Be grateful that the pt wasn't harmed, and move on.
  11. by   augigi
    Hmm.. I've never in 10 years given Lasix IM.

    Unfortunately, there were a few things going on and you're right, this is begging for an error. People need to learn to check EVERY drug EVERY time.
  12. by   Mulan
    Quote from JoycMarr
    Yes, your error(s) could have been prevented, by YOU! Why are you putting blame on others for your mistake? You did not follow the 5 rights did you? Lesson learned, never give a patient medication without doing a chart check first, and NEVER hang an IV bag without LOOKING at the contents.
    No one is perfect.

    We don't practice in a vacuum.

    Yes, it may be an individual person's error, but a lot of times errors are contributed to by things said and done or not said and not done by others.
  13. by   Midwest4me
    Quote from Mulan
    No one is perfect.

    We don't practice in a vacuum.

    Yes, it may be an individual person's error, but a lot of times errors are contributed to by things said and done or not said and not done by others.
    Well said, Mulan! JoycMarr climbed all over kwagner51 without justification!:angryfire We ALL make errors; the environment(and others in that envirnment) in which we practice contributes to MANY of those errors!
  14. by   Lisa CCU RN
    Aren't the MARS checked against the doctor's orders before each shift or q 24 h?

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