med error reporting

  1. i'm a new nurse and just wanted to know what the reality is with reporting med errors...

    my first month off of orientationin med-surg and i accidently gave 2 units rapid acting insulin instead of 2 units fast acting insulin. i got distracted by another (falling) patient while giving meds and saw the sliding scale on the MAR (as far as i knew our hospital only gave the rapid acting sliding scale). anyway, i noticed i had given the wrong drug when i went to sign for having given the med. i was *horrified*. i asked a senior staff nurse and she _basically_ told me not to bother reporting it. i didn't know the nurse (or anyone else on shift) that well. i thought back to everything i learned in school about the importance of reporting errors and safety (and also i felt really guilty and incompetent). i filled out an "incident report" and reported myself. i also rechecked pt's. sugar and monitored him--he was fine.

    while this was a "minor" error i'm well aware that it could have been worse with a different lapse. i like to think that i'm way more careful with meds now (check, check, check, even when you're stressed), even "routine" ones.

    now other co-workers have gotten wind of this and said that i was really stupid for reporting such a "minor" error and that i've now put my license in jeopardy. i'm reading the cases on my state board of nurses and i see license suspensions for things like "two medication errors." also, if this is in my personnel file, can i even leave for another job? i'm freaked. i also don't like the idea of a profession that tacitly condones lying or expects humans to be perfect. yuck.

    am i being pollyanna-ish? do people usually not report these things? for this and other reasons i'm seriously thinking of quiting hospital nursing. too many patients--crazy expectations...
    Last edit by allisonj_rn on Sep 23, '07
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  2. 3 Comments

  3. by   mauxtav8r
    An error is an error.. . or is it? Take a look at some of the studies that ask nurses to define a medication error and you will find that IN PRACTICE nurses often define an incident as "not an error" . . .

    if their other patient was crashing at the time
    if something else more important than giving the meds caused a missed dose ("We couldn't give the dose due to the code we called")
    if no harm resulted
    if the drug given in error was a *reasonable* substitute drug
    etc.

    The list is long of "conditions" that were found to exempt a situation in actual practice from being considered an error.

    But, you are responsible for your license. Keep us posted.
  4. by   Kinky Slinky RN
    When I was in nursing school, there was also a new nurse on the floor I had clinicals on that had given something like 10 units of REGULAR insulin SQ when the order called for 10 units of 70/30 SQ. It was reported to the charge RN who said, and I quote, "don't tell me... it didn't happen... keep your mouth shut." I don't believe it was ever reported. I was shocked then too.

    My only advice is not only learn from YOUR mistakes but everyone elses as well. Because of that incident, I verify every insulin I give with another RN and document their name with the med in our computer charting program (plus, it's protocol to verify insulin dosages but EVEN if it weren't, I would still do it)
  5. by   TexasPediRN
    Allison -

    You did the right thing by filling out the incident report and monitoring the patient.

    Regardless of someone telling you to not report something and ignore it, you still need to follow the policy for it. That nurse was wrong and could eventually make a huge mistake and not report it,and when its discovered, she will loose her license.

    I think sometimes, nurses think that its easier to just ignore a "small" med error instead of going through the required and necessary steps of writing yourself up.

    I've written myself up twice. The last time, the night shift nurse had pulled out the pre-op meds for me and I looked at them, knew in my head that I needed to give 0.15mg of Clonidine, and 5mg of Valium. Clonidine in package was 0.3mg (only one we carry). I knew, and she reminded me, to cut the Clonidine in half before I gave it.

    I walked into the room, compared all meds to the MAR (yes I had it printed right in front of me) saw the amount to give, saw the amount on the pill I had, and gave the 0.3mg anyways. Realized it as soon as the patient swallowed it.

    Now, Clonidine is not a med that requires a waste. I know other nurses that I work with wouldnt have reported it, as dosage wise the 0.3mg was a correct dose for the patient, and we were only to give half.

    I walked out to the desk, and filled out a report after calling anesthesia (no repercussions). The incident report was in my directors hand within 20 minutes.

    I dont know how some nurses dont report it - I cant have that on my shoulders after I leave work. I'd be sick.

    So, we all learn from our mistakes. I'm also extremely more careful with my meds and checking after that incident. I triple check everything. I think sometimes, making a mistake is the best learning experience ever.

    You've learned to be careful, and I highly doubt there will be any problems with you and your license. Large med errors are reported to the board and then a medication remediation class may be required.

    Just my 2 cents..
    -Meghan

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