med error and Sick about it

Nurses General Nursing

Published

after 14 years in the same area of nursing with certification and all I decided i wanted to branch out- check out another interest. I have felt like a "newbie" for sure but this is the challange i wanted

HOWEVER

I have made a medication error! I cannot believe it i have NEVER made an med error, I keep beating myself up about it and now i even wonder if it will be reported to the state board

I have absolutley no excuse all i can think is WHAT THE HECK WAS I THINKING!

i keep trying to rationalize and all i can think is maybe I am trying to force myself in this new envirnment but it really really is distracting..(psych) wayyyy different, i think i should give notice

i took an order that the physicain kep changing but i repeated it several times and at hte end of the conversation she agreed with what i "read back" then i administered a different med... WTH?!?!?!?!? order was for clonidine i gave klonopin

AND i put the wrong time by not using military time ( i am used to working day and this was swing)

when the supervisor called me in i was dumbfounded/embarrassed/ashamed I just couldn't believe it! he reminded me of the 5 rights---OMG! this is what i impress upon students

WHAT THE HECK IS WRONG WITH ME! they must think I am so lame and thank goodness the person is ok I always thought i was cautious but now i am soooo gun shy.

i really don't know these new meds well enough to know if i should be "calling" the physician on the order so that makes me feel vulnerable and i usually run it by someone else

I cant believe I gave someone the wrong medication

I got a verbal warning and signed a paper, i had the oppertunity to put a reason... i don't have one

Do you think my license will get revoked or suspended? I don't have an excuse

it doesnt even matter that it is my only med error in 14years- it is an error -period

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Specializes in 5yrs LPN , 2 yrs CNA.

no you won't lose your license over this. we all make mistakes. the patient is fine so just learn from this and move on. my first med error was a serious no-no! I was just out of school as an lpn 19 or 20...and I did a bad thing. I set up a cup of meds with maybe 6 or so in it. well they weren't in their room so I moved on and put the cup in my drawer. later on then I come across another lady who wasn't in her room and already had her pills set up too. so two cups of meds with about 6 in each and one in each was a big calcium pill. and there other pills weren't the same but same in color....so ya see where i'm going with this??yes I gave a lady 5 pills that weren't hers. I noticed my mistake when I was heading to give the other lady "her medicine"....oh jeeez did I about have a heart attack! I had to call the doctor immediately of course,call the family, tell my don, and report it as a med error to the state. thank God there was no problems or adverse reactions after this. she ended up getting a calcium, two b/p pills(which she was on one herself just a differnt kind), and I believe a stomach med like zantac, and a depression med. well...i monitored her all night, vitals and such. reported to next shift and she was okay. I didn't lose my license. did get wrote up. and learned a huge lesson. Do not set up pills.if they r in a cup find the pt and give it!!!. and check ur 5 rights!!!!! it was an embarrassing and scary situation. but we all make mistakes...so good luck!

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Specializes in PACU.

In my state you wouldn't have your license revoked or suspended for a single medication error that didn't result in harm. Here you MIGHT be forced by the nursing care quality assurance commission to take a CE class on medication administration or something. Who knows for your state, but I doubt you'll get into any trouble.

Your "excuse" is that they have very similar names and you made a mistake--I'm sure it's not the first time that a good nurse has made that mistake. The fact that it's your first error in 14 years suggests you're a careful, safe nurse. Learn from it and move on.

:)

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I can totally understand how you are feeling. I graduated in May and took a job in a very small hospital. We are not very high tech here (hand written MARs, etc) Being new I have made a few errors, transcribing a med as BID but forgetting to put the 2100 dose and just lastnight I admitted two patients and completelty forgot to enter in lab orders for the morning. I feel like the only time I hear from my manager is when I have done something wrong or when there is an incident report waiting for me to fill out when I get in.

Talking to fellow nurses it appears everyone makes mistakes, what's most important is the patient was not harmed. There is nothing worse than that sickness in your stomach when you realize an error has been made.

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Specializes in ED, CTSurg, IVTeam, Oncology.

you know, i could go the blah, blah, blah about the five rights that they drummed into us from nursing day 1, and wag my finger that you should be more careful and let this be a lesson, ad infinitum et nauseam; but i won't. why?

because frankly, there is nothing wrong with you; the fault is with the system. if drug manufacturers continue to name things that sound so much alike, then even seasoned rns with 14 years experience will continue to make the same mistakes. :uhoh3: in the interest of patient safety, the manufacturer should be required by law to change the name.

btw, the clonidine (catapres - an antihypertensive) vs klonopin (clonazepam - a benzodiazepine used in seizure or panic disorder) mistake is probably one of the most notorious error prone pairs within health care. it's been zinging nurses and doctors for years. :down:

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Specializes in ORTHOPAEDICS-CERTIFIED SINCE 89.

Zantac/Xanax is the first that comes to mind

http://www.ismp.org/Tools/confuseddrugnames.pdf

The Institute for Safe Medication Practice put this our. It's a little out of date but you aren't the first nor the last to hear one thing and write a different.

Oh and Klonopin came out spelled Clonopin. They decided changing to a K would fix everything.

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Specializes in MICU/SICU.

ahhh clonazepam klonopin prolly helped bring down the BP anyway, especially even if the pt was a wee bit anxious =)

just curious how you were able to even *get* the wrong med though...did the patient already have klonopin on their med profile?

just thinking about our system....write the order, scan to pharmacy, add order toon preprinted MAR, pharmacy either dispenses to us or enters into the Pyxis depending on what it is. So...if I wrote for clonodine...I wouldn't be able to get klonopin unless it was already on the profile...

have had hydroxyzine & hydralazine PRNS on one patient before

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Specializes in RN, BSN, CHDN.

I used to get these drugs mixed up they sound so alike.

How I got my head around it was klonapin has a p in it and I would think about podiatry and restless legs!!!

So if I was calling for a bp medicine and they ordered the drug I would omit P as I didnt want something to calm stuff down.

i dunno if this makes sense

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Specializes in ER/Trauma, Corrections, Consulting.

Wow...quit beating yourself up!! You are human and made a common error. It happens!! You may have to take a quality review at your hospital but errors without substantial harm should be handled internally and, unless a pattern, shouldn't be reported! Don't give notice. If we all quit over an error there would be no one left!! Learn from it, move on and STOP BEATING YOURSELF UP!! Good luck :)

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Using generic names may have prevented this....(But that is a systems problem...)

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Specializes in home health, dialysis, others.

Don't keep beating yourself up - - you are human, and humans are not perfect. One med error, especially with something oral that did no harm, will not be reported to the BON.

Keep in mind the errors that made the news over the last few years were usually IV meds - like 10,000 u/cc heparin instead of 1,000u/cc.

You will get over this in time. Do not quit this job, do not leave nursing.

Take a deep breath, remember that you ARE a competent individual who has given thousands of meds before this, and will give thousands more.

Take care of yourself, and best wishes.

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Specializes in LTC.

Yeah...and for one med error like that in 14 years..honestly it's minor compared to some errors..like mine. Don't beat yourself up.

Speaking of state..how serious a med error does it have to be to get in trouble with your licnese? I made an insulin error, serious, the resident turned out fine, but I lost my job over it..now I'm worrying about state :( ANd I feel horrible and sick too...

SOrry I drug it OT there for a sec

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