Medication Errors

Nurses General Nursing

Published

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 errors? What can be done to better prevent such errors? Thanks for your input.

Haps

Is there anyone here that says " I never made a med error".

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Originally posted by Cascadians

end rant

:: giggles ::

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Specializes in Med-Surg.

No way!!! I've told my error stories often to illustrate how easy it is to make the same mistakes, and ways to avoid making the same mistakes. I'm so lucky no harm was done by my errors.

I also tell how HORRIBLE it felt to realize the mistake was made and to go through the process of notifying everyone, writing it up, getting counseled by the supervisor........

The worst was watching and worrying about the patient (no harm done thankfully!), and realizing how easily it could have been a disasterous outcome.

Disaster or not, it could have been the end of my job and career.

In my many years of nursing, so many improvements in delivery of care and meds have come from errors and near misses.

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Originally posted by lever5

Is there anyone here that says " I never made a med error".

Surely you JEST!! :roll :roll :roll I had a patient today with a ruptured globe (eye)... eye drops (FOUR DIFFERENT ONES) timed so they were required EVERY HOUR!!!! :eek

like THAT'S going to happen... but I was within the half hour each way rule so.... :: whew ::

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Originally posted by boggle

I also tell how HORRIBLE it felt to realize the mistake was made

Anyone else get that sinking feeling in the pit of your stomach/lightheadedness, when you even THINK you've made a med error?!?!?!

::groan::

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Specializes in cardiac ICU.

OK, I have a question for everybody. I often float to a unit that engages in what I consider to be a dangerous practice. Each shift, nurses whose patients require blood glucose checks write the patient's room number on a sheet of scrap paper posted across from the nurses station. The room numbers are written in no particular order on the left hand side, with one or two blank lines drawn in, to be filled in with blood sugar readings as appropriate (1700 and 2200, or whatever). Since insulin is already one of the most common med-error drugs, I think that this is a disaster waiting to happen. Unfortunately, the unit is also one of the most disorganized, dysfunctional, and dirty that I've ever seen. Should I speak up about this to the NM, when the entire unit is such a mess? Every time I see this it BUGS me.

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I do believe that we are last person who can stop a potential med error. That's a huge responsibility, but one we can't take lightly. I think everyone has made a med error at one point or another, whether it was a med that was late, wrong, whatever. Sometimes I get rushed and it makes giving meds more difficult because I don't feel like I have the time to look up a dose, but I make myself. I don't know every med dosage by heart and there isn't a single soul out there that does. There are some I give so frequently, I do know without looking. Our drs. change units every month and they are often writing orders for meds they're not used to giving. All I can say is, check, check again, double check and triple check. Know your meds, look them up, know your patient, know the diagnosis, know if the med is appropriate or not. Look up the dose, check the frequency, route, etc.., If I don't know the answers to these questions, I get the Dr. and ask. It can come down to life and death. "I thought I had the right (insert patient, med, time, dose, whatever here)." doesn't hold up in court. After all, the road to he11 was paved with good intentions.

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Specializes in inpatient hospice house.

When I worked in the NICU I was about to give one of our patients a dose of antibiotic when I noticed the dose was much too large. I looked it up and found the doctor wrote the dose for an adult. The patient who was 28 weeks gestation was already given the dose 2 x before my shift started. I had to report this to the doctor who was on that morning and the child had to haveh multiple blood tests to make sure there was no damage to the kidney. With further investigation we found that the doctor who wrote the dose had just received news that his father had been in a plane accident right before he wrote the order for the dose of medication, his father happens to be one of the doctors in the unit I worked so the nurses also were upset...All doctors and nurses involved were excellent. Oh yea, the patient didn't have any problems from the overdose and was taken off the antibiotic for couple days and than put back on.

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I hate to say this, but believe it's the truth.....the nursing home where I work, I think the biggest reason for med errors is just plain disorganized, sloppy nursing that is allowed or purposely overlooked by the DON. We have an RN that has worked there for 11 months now and still consistently does not sign out meds -- we never know if she actually gave them or not. The DON knows this and continues to makes excuses. Now I'm seeing other nurses not signing out meds and/or treatments . It's becoming an attitude of "If she can get away with it, why can't I"? Pretty stinkin thinkin if you ask me! It's also the rushing --- not because they have to but they choose to---- we have a nurse that comes in from 5-9pm to help pass meds and do treatments because with low census right now we only have one 8 hour nurse on afternoons. Anyway --- they're allowed 4 hours right --- and they gripe like crazy about having to cut hours and not being able to get things done --- and yet several of them when they work this short shift are done (with everything supposedly because they report off to me that they are) by 8pm and they leave. And then I go to the medbook and find things not signed out. So did they do it or not?????? If you ask them, yep they did. But it's not charted and I was taught that that means no they didn't! *sigh* I'm not perfect, I forget things at times too, but I do my best to insure that I don't. At the end of my shift I sit down with the MAR and go through page by page to make sure I signed out what I did, and then I can see if I missed someone. IF I'm working the short shift, I leave a straw in the book at the necessary page if there's a treatment I didn't get to for some reason and report that to the full shift nurse.

I've tried filling out med error sheets when I find things not signed out and giving them to the DON ---- it just doesn't seem to matter to her.

So where I work ---- I think if some nurses took more pride in their work, and really cared, we wouldn't have the med errors we do.

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Fgr8out ---- yeah, I've had that horrible sinking feeling when I've made a med error, and thankfully it was not one that did any harm to the resident ---- she just slept alot better that night! But I learned from that med error, and have not made that same mistake again --- and that's what it's about --- do we learn from our mistakes (we all make them) or not!

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Specializes in ICU.

Nurses Friends Colleagues! I have just read through this tread and one thing has become clear we are (as usual) taking the blame on ourselves, yes we are giveing excuses (too rushed, too distracted, too stressed) and this has been the traditional approach but isn't it time to take another look at the causes OTHER THAN OURSELVES for medication errors! I am not talking about poor writing on behalf of the medical profession although that is a consideration, or the plethora of "shorthand" orders but the actual system problems that lead to mistakes. HOw "user friendly" are your medication charts? How often do they get rewritten or do you have to wade through 15 chart to find 12 medications? Do you have "standard times" or do you have to write down a list of where and when each and every shift? How easy is it to read the labelling on the packaging? How easy is it to find how to administer the drug (remembering that these issues can and do increase teh time taken to give a medication and therefor increase the stress involved. What is the accepted practice (the custom) within the ward/unit where you work. I have worked in an ICU where it was frwoned upon to look up how to administer a drug - they just put everything in 100 mls and ran it over an hour.) Peer pressure works!

We should think about medication errors the same way we think about workplace safety. Imagine an electrical cord strung across a room with a sign on it saying "Please step over" . This is an accident waiting to happen - no matter how careful everyone is. The answer isn't to blame each other or ourselves from tripping over the cord - the answer lies in making the cord safer.

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Gave Tagamet to the patient in bed "A" when it should have been the patient in bed "B" on night shift at the nursing home. But let me give you the background of this incident. Was fresh out of nursing school (LPN). Had never worked a day in my life nursing or otherwise. Was my first night on the job. Was the first time without a supervisor over me. Put me in a 70 patient unit on the 3 to 11 shift. Had NEVER passed meds by myself. Was the only nurse at my desk in charge of 2-3 aides. Was still passing my 8:00 PM meds at 11:00 PM. Wanted to quit after that first night. Only other nurse was another LPN at her desk with same amount of patients. Only worked there 7 months but it felt like 7 years. I reported my mistake to the day head nurse and recorded it in the chart and was absolutely scared to death. The most terrifying night of my life.

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