med error not sure how to feel!

[erin01]

SO I got pulled aside by one of the senior nurses, who told me I had a med error. Now this is a nurse who has before chewed me out in front of others on something else. I was already on defense when she said she need to talk to me. She told me that i had given a man to many pills of vyotrin or something like that and could not remember his name. She said that the md had written the order wrong and i gave it. I vaguely remember because it was a lot of pills. I started to remember going back to the chart and checking the order. I have given meds that were a few pills d/t pharm not having brand, or exact dose pills. I remember it was a cholesterol drug, and it was not a huge flag to me. I have seen liptior 40 mgs ect before, and he was not a small man and had a history of high cholesterol. And i work on a cardiac floor so i think he was there for chest pain. So she said the patient called when he realized the error because it was a different than the dose that he was taken, and they had to call poison control and i was written up! i feel bad, but also confused. I did not go to medical school, i Am not a pharmacist, how could i have handled this differently? I asked the nurse and all she said was experience. Well i am only a rn 7m? What if the patient decides to sue? I dont see how i would catch and error like that? Any thoughts or suggestions?

[Katie5]

Sorry about that. Makes one feel sad. Was your patient harmed?

[proudnurseRN]

So, if I am to understand this correctly, the physician ordered X dose, the pharmacy put it through, and you went back to check the order and verified it said "X" amount?

The problem I see is that you weren't familiar with the drug. At the very least you should be able to know what the drug is for and safe doses. If you had checked that, abd it was a safe dose, the doctor had ordered it, and pharmacy had put it through, I'm not sure what else you could have done. But if it was not a safe dose, then you are partially at fault. As nurses we are the last safety net in med dispensing.

[delilas]

I'm with proudnurseRN - if you do not know safe dosages offhand, then you need to check a med book before giving the medication - thats the only thing extra you could have done. If everything else was in line, I don't see how it falls to you. If the patient wasn't harmed by it, you shouldn't worry too much about a lawsuit as yet.

[Leecy]

First, take a deep breath. If every nurse who made a med error were fired, there would be no nurses. Personally, I think there are two kinds of nurses. Nurses who will tell you they made a med error, and nurses who are unaware that they have ever made a med error. It next to impossible to have worked for a few years and not have made an error. In you case, the system failed the patient. The physician made the initial error, pharmacy didn't catch it and neither did you. It's not all on you alone. In the unlikely event of a lawsuit, your institution should not only have lawyers, but a risk management team and administration would be on your side. It is in the hospitals best interest to be able to say, "We are very sorry this happened. We are taking a look at how orders are written and checked so this doesn't happen to anyone else." In large hospitals there is computerized order entry which would have alerted the physician to his error. A pharmacist would have checked the order and entered it electronically creating more double checks. The RN is alway the last check. Even though you are rushed for time, try to look up you meds, and always ask the patient, "have you taken this med and this dose before?" That last question has save my butt more times than I can count. Even with computer orders, pharmacy, PYXIS alerts, etc. We are still far from perfect, we have all been in your shoes, and we still have our jobs where we can tell new nurses what we did one shift and how we survived it.

[Zookeeper3]

Look, you will make many errors in med passing in your career, the first is terrible... well so is every one after that.

Just like us nurses, the docs make mistakes too. We are the first line of defense to prevent this, pharmacy the next.. or equal to us. Everyone has ownership when an error like you mentioned occurred.

You obviously have excellent med pass practice as you told the patient his med and dose. Being new, it takes you so much longer to do EVERYTHING and you trusted in the system. Well, unfortunately, you must look up every drug that you're not familiar with.... it's the only way you will learn what the drug is for, interactions and usual dosages. I'm sorry, but although you are under tremendous pressure, you HAVE to do this until they are familiar. Just like school... I still look up drugs 15 years in. And I've made my fair share of errors too.

Hopefully you have a committee at work that looks at errors and formulates a plan to prevent them again. This was a system issue... and you were a part of a link that failed.. as did everyone else.

This patient cannot sue if no harm came, and please understand that that is not your worry, HARM to our patients is.. if there was no harm, there should be a review of your facility practice to see what broke down, a fix of the problem.. and that's it.

That write up will stay in your file, in case you have additional events in which you don't assure safe dosages. That is your responsibility, no matter how pressed you are.

This is a very tough profession to the new nurse, and your not alone, we all struggled to gain safe practice. Just don't take that shortcut again, and I promise you'll be good.

I wish I could take the worry away, but it's a great reminder to be more diligent. We all benefit from that.

take care.

[morte, LPN, LVN]

SO I got pulled aside by one of the senior nurses, who told me I had a med error. Now this is a nurse who has before chewed me out in front of others on something else. I was already on defense when she said she need to talk to me. She told me that i had given a man to many pills of vyotrin or something like that and could not remember his name. She said that the md had written the order wrong and i gave it. I vaguely remember because it was a lot of pills. I started to remember going back to the chart and checking the order. I have given meds that were a few pills d/t pharm not having brand, or exact dose pills. I remember it was a cholesterol drug, and it was not a huge flag to me. I have seen liptior 40 mgs ect before, and he was not a small man and had a history of high cholesterol. And i work on a cardiac floor so i think he was there for chest pain. So she said the patient called when he realized the error because it was a different than the dose that he was taken, and they had to call poison control and i was written up! i feel bad, but also confused. I did not go to medical school, i Am not a pharmacist, how could i have handled this differently? I asked the nurse and all she said was experience. Well i am only a rn 7m? What if the patient decides to sue? I dont see how i would catch and error like that? Any thoughts or suggestions?

presuming that vytorin is what you are talking about this is how it comes

What does my medication look like?

Ezetimibe and simvastatin is available with a prescription under the brand name Vytorin. Other brand or generic formulations may also be available. Ask your pharmacist any questions you have about Vytorin, especially if it is new to you.

• Vytorin 10mg/10mg - white, capsule-shaped tablets
  
• Vytorin 10mg/20mg - white, capsule-shaped tablets
  
• Vytorin 10mg/40mg - white, capsule-shaped tablets
  
• Vytorin 10mg/80mg - white, capsule-shaped tablets
  

it would appear the pharmacy made a large error in sending multiple tabs, since any dose has ONLY 10 mg of zetia...good luck

[Up2nogood RN, RN]

SO I got pulled aside by one of the senior nurses, who told me I had a med error. Now this is a nurse who has before chewed me out in front of others on something else. I was already on defense when she said she need to talk to me. She told me that i had given a man to many pills of vyotrin or something like that and could not remember his name. She said that the md had written the order wrong and i gave it. I vaguely remember because it was a lot of pills. I started to remember going back to the chart and checking the order. I have given meds that were a few pills d/t pharm not having brand, or exact dose pills. I remember it was a cholesterol drug, and it was not a huge flag to me. I have seen liptior 40 mgs ect before, and he was not a small man and had a history of high cholesterol. And i work on a cardiac floor so i think he was there for chest pain. So she said the patient called when he realized the error because it was a different than the dose that he was taken, and they had to call poison control and i was written up! i feel bad, but also confused. I did not go to medical school, i Am not a pharmacist, how could i have handled this differently? I asked the nurse and all she said was experience. Well i am only a rn 7m? What if the patient decides to sue? I dont see how i would catch and error like that? Any thoughts or suggestions?

It is a terrible feeling I know to make an error. I haven't had another nurse point it out but have caught it myself. The pharmacy was the one who first made the error in my case by starting fragmin the first post op night instead of 11am the next day like the MD ordered. It came up to give at 11pm not thinking to double check because the pharmacist entered the order.

We are not doctors or pharmacists but they are human and make mistakes too. We are the ones who administer and it is our responsibility to double or triple check the meds we give. I always look at several different things and ask the patient before

giving. I took a phone order recently from an MD to change a pca to dilaudid 2mg Q 6 min.... Now if I would have administered that dose it probably would caused harm. Luckily we have great dogs and I entered the appropriate dose and let her know in the am when she made rounds and she thanked me. It just takes diligence and time to check appropriate doses don't beat yourself up just use this as a reminder to always check your meds.

[mamamerlee, LPN]

Generally speaking, in our unit-dose systems of today, the rule is not less than one-half of a pill, not more than 2 pills. There will be exceptions, of course, but they should be rare.

And why would another staff nurse tell you about this? Where is your manager? Did you see the incident report? Usually you get to discuss the incident, and how you can avoid future errors of the same kind.

Take some deep breaths, and know that everyone makes mistakes.

[SkiingCait, BSN, RN]

I have a somewhat-related question for you experienced nurses out there. I am finishing up my last semester of NS and at my last clinical, I overhead a situation that got me thinking. There was a patient who was one a medication (wasn't my patient, and I'm not sure what the med was), but the dose was MUCH higher than a normal dose for this medication. I heard the pt's nurse ask the manager if this was normal, as it raised a red flag when she was prepping his meds. The mgr just responded "that's what he gets, just give it". What got me thinking, however, is if the doctor did in fact write for a higher-than normal dose, as the nurse do you give it, even if it doesn't seem right? Just wondering if any of you have ever encountered this is the past, and how you would handle it?

Thanks,

Cait

[proudnurseRN]

I did have that situation arise recently. I pulled up the information on MAK... and though..."hmm, that doesn't look right." So I looked at the chart, it was ordered as such, from home medications. Because my pt was alert and oriented, I asked them, and they confirmed they do take 6mg of Lunesta every night.

[pandora72, BSN, RN]

i have a somewhat-related question for you experienced nurses out there. i am finishing up my last semester of ns and at my last clinical, i overhead a situation that got me thinking. there was a patient who was one a medication (wasn't my patient, and i'm not sure what the med was), but the dose was much higher than a normal dose for this medication. i heard the pt's nurse ask the manager if this was normal, as it raised a red flag when she was prepping his meds. the mgr just responded "that's what he gets, just give it". what got me thinking, however, is if the doctor did in fact write for a higher-than normal dose, as the nurse do you give it, even if it doesn't seem right? just wondering if any of you have ever encountered this is the past, and how you would handle it?

thanks,

cait

absolutely not! when in doubt, don't give it until you look it up and/or clarify with the md. you can't imagine the number of times i have double checked the safe dosage range for a child's weight only to have it out of whack. understand though, that some medications have different dosages for the same weight based on what they are being given for ie antibiotic for upper respiratory infect vs meningitis. first, i call rx to let them know i think it's too high or not then call the md to let them know what rx and i are questioning. i always call rx before the md because sometimes it's a matter of a reconstitution error or crazy math that can be resolved between us.

just always remember... one of those 'rights' is dosage. that not only refers the right dosage as prescribed by the doc but did the doc prescribe the right dosage? you give it, so you are ultimatley responsible.