Medication Errors - page 2
I am doing a research paper on medication errors. Curious as to what nurses think about this subject. What do you think are the most common medication errors and what are the most common reasons for... Read More
Oct 3, '01I agree with the comment about taking respondsibility for a med error. We are all human and are destined for a mistake as some time but to not take respondsiblity for it has far more severe consequences. I worked with a cardiologist at a hospital that ordered an IV dose of digoxion that was about 10x more than should have been. The 6month old was in a stable SVT and need a loading dose. When the RN went to give the med she questioned the amt and was hesitant about giving it. The MD kept saying it was fine. She finally gave it.The pharmacist, who normally would have double checked the dose was on break and the dose was handed over by the tech. When he saw the amt. he rushed to our unit and said not to give it. Unfortunatley, the dose had already been given. The infant, after a day long battle with a variey of arrthymias ended up dying. The physcian went back to the chart and "doctored the account" of what happened. Never at any point did he accept any respondsiblity for the event. The poor nurse ended up leaving the unit. She did come back to nsg. but in an entire different capacity. The physcian had his hand slapped and that was all!!!! But the point is, had he acknowleded his mistake at once we may have been able to make a difference in the outcome of this infant.:
Oct 3, '01Funny this topic just happened to come up today----
So JAHCO reviewers were at the hospital today. I only had a few patients that day, and when my supervisor said to gather a couple of my charts to be reviewed, I picked any two I thought was the most complete.
Earlier in the morning, I happen to go in to a patients room and since I only had three patients I tried to do more primary care with this patient. I took his B/P after the morning cares. 220/96
I rechecked this B/P 214/90 manually. I rechecked the trends on this patient. He had been varying degrees between 180- 230's. The evening shift had called when his B/P was 230 and Metoprolol 25 BID was ordered. B/P didn't go down very much between the next couple of hours. So when I saw this B/P at 730 in the morning, I saw that he hadn't had a dose of any B/P meds. (When pharmacy schedules meds, they just pop up with a preprogrammed time i.e. 0900,etc) I gave two B/P meds that were ordered for QD. Under the times of the meds, I crossed out 0900 and placed 0730 with the B/P written under each signature. When I was getting ready to call the doc, he rounded the corner and wrote for new orders. He wasn't concerned that I had given the meds, he said that is what I should have done anyway. So off he takes the chart. I don't see the chart until after 0930. Then the time is called for chart review. I had intended to write a note on what occured, but was unable because of the chart review.
When I needed another chart, I went into their little conference and was asked point blank why I gave the med early. I explained the situation. Later I was to find out that if I hadn't walked into the room that it would have been written down as a med error. But when I explained myself, that cleared it up. Does anyone understand how this can be a med error.
So what does this say about our patients that leave the floor for dialysis or have to have a med held about a procedure. Anyone know where I am coming from? AM I WRONG AND IGNORANT?
Oct 3, '01theres a difference between doing your job and doing your job on paper.
you were right and conscientious. you know they have to find SOMETHING
Oct 3, '01You are not wrong.
Your are not ignorant.
You did what any good, reasonable nurse would have done.
Next time however make a note somewhere even if the language/syntax or whatever sucks.
In our hospital AM meds started with the MAR that began at 0800. SO therefore if you had documented on "yesterday's MAR" it might have been overlooked by a new person looking at "today's MAR.
Plus JCAHO....don't even get me started.........
One year the guy took the charge nurse to the code cart, and for nearly 2 hours quizzed her on everything about it and its contents. They never even looked at a chart on our floor.
Oct 3, '01I think the most common reason for medication errors is being "too rushed". When we don't have enough time to take those precious extra seconds to be careful med errors are just waiting to happen.
I would think a most common error would be wrong dosing. For instance if a ptl. is to receive 25 mg. of lopressor. The nurse has a 50 mg. pill. In haste she gives the entire pill rather then breaking it in half. I know this has "ALMOST" happened to me several times. I thank goodness I have done the double and triple checks that prevented these errors. But, when rushed I can see errors like this happening.
Oct 4, '01I definitely agree that the reason for most med errors is being rushed and interuptions.. mar changeout has caused significant errors.. the mars and po's were not being compared and that was causing big problems. I had to do med pass with the head CQI Nurse for the region well it didnt go so well. my med pass procedure was great but , the mars did not read accurately. when it said 0600 the order read qd so that meant 0800 instead i had several errors like that due to the medical records person not knowing the policy for times.... but most of the time time is the problem, you can either be a paper nurse or a floor nurse it is almost impossible to be both..... goood luck..
Oct 4, '01Be this as it may...being rushed...or feeling rushed is certainly the number one answer here. But...as my mother always said .... " The person who has never made a mistake...has never done nothing"....This holds true to nursing as well.. We all learn from every mistake we make. I've made a couple of med errors in my career..Fortunately, neither were life threatening. They DID however stick in my mind...and I can honestly say I never made the same one twice.
Oct 5, '01frustratedRN:
I have just started working in the ED - here in Aust we don't insert IV's on the ward - we have IV teams to do that - ANYWAY - despite 13 years of experience I have never put in an IV - I did no. 7 the other day in the ED and blew it - in one side of the vein and out the other, great big haematoma. I went and got someone more experienced and she told the man involved that she would put in the IV. He said "no you won't". She said "why, don't you want an IV in now?" His reply was "Yes, but Julie can do it, she needs the practice". Honestly, I could have kissed him!!
A lot of patients realize that RN's, regardless of what sort of experience they have, are not perfect at everything. Everyone makes mistakes - people are more likely to empathise with you if you tell them the truth.
Oct 5, '01We just had a med error today at work. I was covering another nurse's patients while she went to lunch. She had a post-op patient who was complaining of nausea. I went and looked at the MARS to see if any nausea meds had been ordered. Sure enough, there was and no one had signed they had given the med. I drew up the Phenergan went and administered it to the patient. I came back and signed the MARS and returned to my station. A few minutes later, the nurse returned to the floor. She came down and asked me if I had given her patient some Phenergan. I said yes. Well, she said another nurse had just give her same med 10 minutes before I did. I told her I didn't know because it hadn't been signed off on the MARS. The scary thing was, I was going to also give this patient some Demerol also but her nurse returned before I could get the medicine. Good thing. Evidently, the other nurse had also given the patient Demerol and not signed it off on MARS!! She put it down on the nurse's brain board. I was ticked!! I could have double dosed that patient twice . Moral of this story is: If you give a med, sign the blessed MARS for pete's sake!!! Fortunately this patient was okay, but it could have caused serious problems!! And another scary thought about this incidence is the nurse who gave the meds without signing the MARS is training to be a shift supervisor! She hasn't even been a nurse for a year!!
Oct 5, '01oz
my first IV was on a weirdo woman in medical short stay. the nurses were explaining the procedure to me and this patient is just lying there all worried.
are you new?
no, im a nurse on another unit and i need to enhance my iv skills.
we dont have the opportunity to place that many where i work. (translation...ive never done this)
well i didnt even get the iv needle started and she was screaming and carrying on....lol
its so cool to have a pt be so understanding.
its unusual. ive let ppl practice on me too. im not afraid of needles.
its nice when you come across someone who kinda knows where you are coming from
Oct 18, '01my first night shift as an rn, i arrived on the ward to find that not only were there only 2 qualified nurses to 48 pt's, one of the senior nurses on the previous shift had made a pretty big drug error - we were told that she had given 30u of insulin instead of 10u to a patient whose bsl's had been all over the place anyway. it wasn't until 15 mins later when we went to check her again that we found out she wasn't diabetic.
we were lucky - the sho had acted very quickly and with glucose running iv she didn't go hypo....but it still scares me when i think of what could have happened. the worst thing was that the nurse who had made the error was so mortified by what she had done, she just picked up her coat and left. didn't lodge an incident report or med error report or even sign the nursing notes. nowt. can you imagine the legal mess she would have been in if the patient had died?
Oct 18, '01when you do something like that its hard to think straight. its a hard thing to face making a mistake like that and realizing what the consequences could be.
i know when i gave that insulin i kept telling myself over and over....i could have killed her....i could have killed her.
it was cowardly for her to run. i stayed. i faced the music and i was the one who did the accuchecks q15. i was the one who monitored her. i made sure she was ok and that i had done every single thing i could to try to make it up to her.
when i was a student, my instructors and other nurses told me that it was a good thing that happened to me in school. i disagreed. i thought it was an awful thing to happen in school.
now i see what they mean. if nothing else that mistake has made me more diligent about med administration
Oct 18, '01Interesting to read the posts on drug errors. I think being rushed is a contributing factor but if you abide the 5 rights & keep SAFETY first then no matter how rushed you are errors can be detected before the meds are given.
What are your policies on parenteral meds? Where I work (in oz) all parenterals are double checked (IV, IM, SC) including all infusion bags with or without additives.
If insulin is given, the second nurse needs to know the BSL. If ca hep given with warfarin, the 2nd nurse always asks what the last INR was. Not that we don't trust our peers, this is just one of our hospital's safety measures.
We also have great pharmacist that checks the drug sheets each day identifying any wrong doses, drug interactions, etc.
MIMS are always on hand, if its a drug you aren't familliar with, take a moment to check the usual dose.
I know things can still go wrong but we have to be pro-active in our practice & implement policies to protect our pts and our licences. We all have 60 minutes in an hour, this is no excuse.