I have just made the inexcusable mistake of giving a patient of a long term care facility the wrong medication! The occurrence was Sunday 3/31 and as an agency licensed practical nurse I did not know the residents, the staff or the routine of that particular floor.
When I prepared the medication, I assumed I was in the right room with the right patient. WRONG! I gave 50mg Lopressor to the wrong patient and I realized my mistake just as I happened to glance at the wall where her name was posted. She was not wearing identification. I immediately reported this to the supervisor and the patient was monitored for s/s of adverse reaction.
The outcome was not good. Her blood pressure was inaudible within a few hours and she was transported to the hospital where she ended up in ICU. It was not until Tuesday that her condition became stable from the medication I gave.
My question to other nurses, is "Can my 20 year career be over?"
This has been a week of pondering and I still have not resolved this in my mind. One thing I would recomend, if anyone asked me, is that pictures of residents always, always be placed on the medication administration record.
This might have prevented me giving the medication to the wrong resident.
What do you think?
Apr 8, '02
I can only sympathise, since the systems in which we work are so different. We use photos on the med cards on my Elderly Mental Health unit, as the patients will often answer to another's name, and invariably worry away to destruction at their ID bands.
More enlightened places see a med error as a system failure, once it has been established that no malice was intended. Were you properly oriented, were there sufficient staff, was the name you saw posted in an obvious position, etc which may have led to the error.
Nurses are often devastated by these events, even without the result of this one, but are all only human, and therefore fallible. Let us know how things go with you.
Apr 9, '02
I have made med errors myself but never with such a bad outcome. We all make mistakes and I hope that this would not cause you to leave the profession. Personally I will not give medication to anyone who is not wearing a ID band. When I find a patient without one a call the supervisor and have her make one. I don't like pictures. Many times they not head shots and a lot of little old ladies and men look alike. Also I noticed that the faces of patients who have dementia change and facilities don't update the photos.
Apr 9, '02
We are all human. I have made med errors, as has every nurse who has worked more than a few minutes. Occasionally we acually catch the errors ourselves, and are able to keep track of the patient and the outcome. You said your pt's condition stablized. Learn from this. Go on! You are a good nurse. Believe in yourself, and use this as a reminder to keep at the top of your practice.
You can get there from here!
just my $ .02
May 8, '02
I was once orienting a NEW GRAD to the unit when I made a drug error. I read the order. ..an IVPB abx, 500mg. I pulled the bag out of the fridge and read the label..name, room number, drug name, and dose..1000mg. I read the order again..500mg...looked at the bag..1000mg...checked patient ID.. Hung the bag and set the rate..walked out of the room...orientee at my heels, and after a full 10 minutes it hit me !! I ran back into the room and pulled down the dose (52 cc's left of a 100 cc bag)...phew!!!
And told the orientee what I had done. I then explained that she would get the most needed lesson in nursing..what to do when you make an error..and you will!
1) ADMIT IT!
that can be the hardest part, but once done the rest is easy! You can never undo any possible damage unless you alert the staff to the possibility that it could occur!
The patient is your first concern, so prompt reporting to the medical staff is essential!
also...when mistakes do go to court the cases where punitive damages are added are those where someone tried to lie or hide the truth! When an attorney decides to take a case to court he/she makes the decision based on DAMAGES.that is, how much MONEY is the injury worth? The faster you report an event, and steps are taken to prevent harm, the less damages result. Early intervention can be the thing that prevents an attorney from accepting a malpractice suit against you!
2) Accept it. We are human, we are overworked, tired, usually hungry and always rushed!
3) Learn from it. As redundant as that is! I read the order from habit! Never again.....You failed to properly identify a client.NEVER AGAIN, right?
May 8, '02
"..what to do when you make an error..and you will!
1) ADMIT IT!"
Truer words were never typed, TIREDmidnightRN....
Whatever the case... ACCOUNTABILITY should be at the forefront of our thoughts... second only to the patient themself.
Take a deep breath, Sassy... we're human and mistakes do occur regardless of how diligent we may be with the "5 Rights" of drug administration. It only takes a moment for something to distract our attention and make a med error.
Whatever you do, DON'T QUIT. You'll never forgive yourself that action if you do. And you'll cheat yourself out of future positive outcomes in other situations.
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