Suspended for a Medication Error - page 3

The Act I was a new nurse, and before I had even gotten my feet underneath me, I lost my footing and fell hard. I made a medication error. I was fresh off orientation as a brand new nurse... Read More

  1. by   Kooky Korky
    Quote from prmenrs
    Any error (esp. a med error) should always be viewed as an 'organization' error. Analysis of the error should focus on where, in the process of administering the medication, the error could have been interrupted. It should never be "whose fault is this", but how could the process be altered so that it doesn't happen again. No one should be singled out. Sure, the nurse who made the mistake will know, and feel guilty, but she should made to be part of the problem solving. "How can we, as an institution, make it more difficult for an error like this one to occur?"

    Sometimes, as the group analyzing to error works together, it will turn out that, by changing something simple, the nurse would've paused and caught the error before it happened.

    A few years ago, a colleague was about to flush an IV w/heparin (as we did back then). She selected Heparin 1000U from the PYXIS, which dispensed it. It came in a little vial w/a blue stripe on the label. She drew the med up in a syringe, disinfected the port, and looked again @ the vial. Turns out, the vial contained 10,000 units of heparin, not 1000u!!! Our unit didn't even use that strength Heparin! She called pharmacy. Pharmacy tech that filled the machine thought s/he had put in the 1000 unit vials. Both vials were the same size, and both had a blue stripe, but a different shade of blue. Pharmacy got in touch w/the FDA. Ours was not the only place where this error had happened, or, in our case was a 'near miss'. Eventually, the manufacturer was compelled to change the packaging to make it harder to confuse.

    My point is that patient care delivery has many components, and many, many ways to mess up. We need to resist the urge to point a finger @ an individual, acknowledge that there are lots of ways to make a mistake, and it behooves the institution to analyze errors, and find ways to help NOT make an error.
    One of the best ways to avoid errors is to get doctors to stop yelling and for nurses to accept verbal and phone orders only in an emergency.

    These should be issues that Management should address.
  2. by   Kooky Korky
    Quote from Jmmfan1
    So I am not a nurse but wanted to share this with all of you still. I see how hard the nurses and CNA's work. I am a patient and this is my fourth facility. My second facility I was in I had a nurse come in at 2:30 in the morning, flipped on the lights and said I am here to give you your shot! I said Shot? What kind of shot? He then told me it was my Insulin shot. I said Insulin? I am not Diabetic! He said oh you are not? I said no I am not. He then said I must have the wrong room. I was glad I caught it the first night and the second and third night. After the third night I told the DON (I reminded the nurse the other two times.) I also told the DON I did not get my meds the night before. She talked to him because he came and tried to convince me he had given me my meds. My meds had been counted to which he replied well I know I gave her some meds!! At that point he was put on suspension, the DON was fired and he came back within a day. The Center Director told me I made accusations against his staff. A month later or so he passed away of a overdose. I am not putting blame on him persay how ever there was evidence he was rushing through his med pass. My concern was the possible of insulin shots when I am not diabetic. I had seen this in another facility I was at. When I did HR and Payroll I made sure I had checkpoints in place to ensure my work was correct. Is there anyway of adding checkpoints to med passes as well? And the doctor that barked orders, did you repeat back what he told you? Thank you to all of you for what you do.
    This is pretty terrifying. Maybe a report to the accrediting bodies is in order.
  3. by   KellyBeeRN
    Thank you for sharing this story. I had a similar experience in nursing clinical. Good thing it was clinical as I didn't actually hang the bag, but I know that anxious, excited-to-prove-I'm-smart feeling. It totally bite me in the ass and I still carry it with me 10years later. I'm always reminding myself to slow down and follow the process.
  4. by   Nurse3000
    Was new grad end 2015 - didn't know how to read insulin needle.. drew up too much, not confirming amount I stupidly asked for check/without verbalizing that I didn't know how to read the needle and expecting the second check nurse to draw up right amount.. it was reported and BOY did I get the coals raked for me to walk over!!

    The next day managers/educators were in cahoots. I Wasn't allowed to give a Panadol out by myself. Was shameful embarrassing and felt like everyone knew... b***** colleagues lost trust in me and did not support me. Wasn't allowed to give out ANY meds without an educator, manager or other R.N. there next to me. I left half an hour late after every shift for 2 weeks just waiting for someone to watch me give out tablets.
    It dragged on, I wasn't allowed to give any injections intravenous subcut or otherwise whatsoever for at least a couple of months until "review" by a new grad educator not known to the ward... Was given unnecessary attention/meetings nearly every get me up to scratch (unlike other new grads)
    My near miss was rubbed in NON STOP on top of the demands to do job.
    It was A HUGE overreaction and loss of trust in me for pulling up the wrong amount of insulin and expecting someone to fix it up for me.
    it completely Ruined my year and reputation and I became so anxious I could hardly breathe half the time...instead of making things better, it just all got out of control I put on 15kg and HATED myself. I HATED my self as a nurse... I hated the job, (not looking after people.. ) but the mere politics of it. It's still affecting me to this day... and because of that experience, and it's consequences relating to my confidence, self esteem, belief in myself, broken weak version of myself and personality, my reference is Not strong as well and I'm only working agency at the moment... I haven't worked full-time since July last year (7 months)... I feel like maybe full-time nursing is not on the cards for me, it's not meant to be...??? (Part of that attitude is confidence Stuff) but part of is it a pressure to work full-time nursing hours.
    Maybe I can just work part time and/or just a regular job with casual part time nursing hours in between... Screw the prestige of saying I'm a "Registered Nurse", or only being a Registered nurse ~~ I'm over it! [Plus I'm 31 years old and down to earth!] The politics are the killer!!!
    Last edit by Nurse3000 on Feb 22, '17 : Reason: Spelling, addendums
  5. by   MomBabyUnitRN
    It can be hard to forgive yourself when a med error is made. I still remember my first med error; gladly, it has faded over the decades. I had floated to another floor which was common back then. It was a written order, but at our small hospital, we had no pharmacy at night, yet, they were supposed to fill the patient med drawer with the appropriate meds. When I went to give it (it was a cardiac med) it wasn't there. So I called our house supervisor who had to go to the pharmacy, unlock it and get me one and bring it to me. My fault was not checking what she brought me, but I assumed that it was the correct med. I took my patient in the meds and all was well... the next day, the pharmacy caught my error as she has signed out the wrong med to give me. My supervisor called to tell me I'd given a beta blocker instead of an ace inhibitor or vice-versa -- I don't recall. But I do recall the conversation. She's still a friend to this day and I'm grateful she used it as a teaching moment instead of a blaming and shaming moment.

    No harm came to the patient, but I learned my lesson that giving medications are to be checked, and double checked and using those 5 rights, I would have caught it myself. I didn't have the right med. Stupid mistake and I was totally in the wrong. Kinda like drawing up a medication and expecting another nurse to use it. (Yes, I've seen nurses do that) I'm no longer doing bedside nursing, but teaching now. I wish we were all perfect. We're not. No one is.

    Forgive yourself. You're going to go on to be a great nurse and help many people and save lives. Best of all, forgive yourself.
  6. by   Tmn719
    Loved your article. I was suspended and then made to retire early or get fired due to a chronic medical condition. Still pining over this was a psych nurse 4 twenty 4 years any advice ? Law suit in progress
  7. by   Dragonnurse1
    I worked in an ER for 9 years 4 months and 17 days all of them on nights except for my first 2 weeks right after graduation. I had a physician tending to a patient with an injury to her nose. This physician told me to draw up 25 mg Valium and even though I was a new graduate I was shocked and paused. He repeated the order for 25 mg Valium, so I went to pyxis and drew up 25 of valium. I walked back into the trauma bay and while holding onto the syringe I said valium 25 mg. He turned on me and yelled "I said 5mg" before I could answer the patient said "No you said 25mg" and I replied you said 25mg. I still had a death grip on the syringe. He turned redder than a coke can and said "I meant 5mg" in a very subdued voice. To which I pulled out the other syringe I had with 5mg of valium in it and went and wasted the 25mg of valium. That was the closest I came during my time to making a medication error. I have refused to give medications because a physician ordered the wrong route and refused to numb a 2 year old with 2% buffered lidocaine (the physician numbed the child and that child ended up in a children's hospital overdosed on lidocaine). I have given methylene blue to a patient when no one else would take a pyridium overdose. I took orders over the phone in the middle of the night from physicians who did not want to come in but also did not want the ER Doc to see the patient, insisting that the physician on the phone listen to me call the orders back and I have had the ER Doc to see private patients because their attending would not come in to lay eyes on. I have taken orders for 2 beers with meals and I have had ER Docs ask me to go start working up patients before they got in the room because they were swamped and made a couple mad because I have caught their errors. But that one close call with a Physician made me find my voice and learn one very important thing in the ER, always call back the order to the Doc before pulling medication from either the pxysis or the narcotics box.

    PS The reason for knowing exactly how long I worked is because I had to give up nursing due to a sudden and violent latex allergic reaction. Funny I miss nursing to this day but at the same time I am glad I am out of the profession. I do not think I would like all the newer rules.
  8. by   Ruby Vee
    Quote from hewert
    Verbal orders are prone to errors. The trend is to require all med orders to be written by the prescriber with the exception of "urgent" orders. What is your hospital's policy on this? If you were not noncompliant with a written policy, you should not be punished! 'Course the docs find this policy "inconvenient" but it is being successfully used now in many hospitals
    As I read it, the situation happened years ago when verbal orders DID happen. Hospital policy said they were OK as long as they were signed in eight hours or 24 hours or whatever.
  9. by   Ruby Vee
    Quote from nursegj
    One thing is almost certain (I say ALMOST) is that this will not happen to you again. I have been a nurse for 40 years and I too made an error as a new grad. I swear, my life flashed before my eyes. It was horrible. My Head Nurse was supportive and backed me up but I beat myself up pretty badly. I can say, that in 40 years I never made another med error. That was it for me. I was careful and accountable from that day forward. I followed the procedure: check, recheck and recheck again. I have not let speed or someone "barking" at me make me break protocol.
    Don't beat yourself up too much. It happens to almost everybody. Just be careful and follow whatever your med protocol is. Don't be afraid to question orders if they don't make sense. Remember, no matter how the error originates, it is the person actually administering the medication that is most liable if something goes wrong.
    Unless you are not actually human, I find it difficult in the extreme to believe that you've never made another medication error in 40 years. I suspect you've made a few you don't know about. No human is perfect.
  10. by   IrishCMSRN
    maybe if we were not all over worked, with too many patients, and too much endless documentation we might not make mistakes. Oh but Im sorry, nurses are supposed to be robotic and invincible. I was FIRED for forgetting to document someones restraints after a night of pure hell!. Its an awful feeling. Nurse Manager treated me like I had just killed someone intentionally!
    This is what makes me not want to be a nurse anymore....
  11. by   emmafrancis
    I watched this happen one day when I was charge nurse on a floor. I was not the nurse giving the meds, but I saw a nurse come out of a room, then I saw the color drain from her face. She had just given a bunch of meds to the wrong patient.

    We acted quickly. I paged the dr to come, and we did the best we could to negate any effects the wrong medications would have on this patient. The family was notified and the nurse sent home.

    I had a meeting with my manager about it a later that day and we discussed the reason for the error.

    Our system allowed the patient to be scanned after meds were scanned. This meant that the nurse had to check ID and come out to the machine and check to make sure she had ID'd the patient correctly. What an easy place to make a mistake. I suggested that the patient needed to always be scanned PRIOR to any medications.

    A few months later, we got a new system. As we had discussed, scanning medications prior to scanning a patient is disabled. The program also makes a noise if you have a patient pulled up and scan a different one (we tested it a few times when we first got it).

    When there is a med error, it is very important to find the process that failed as much as it is the nurse. Our process allowed her to make this error and we got it fixed.
  12. by   BklynHeightsRN
    We effectively learn from failures, not successes. Yes, a medication error, but it's not like it was IV potassium chloride. Some people may say there's no difference but I disagree. For high alert meds I doubt any of us would take a verbal order, and we would confirm confirm confirm. I don't consider D5W a high alert fluid necessarily (unless maybe the patient were diabetic but even then, insulin can correct that, it's not like that patient would die from the error).

    The one and only time I made a medication error was in the ED when I gave the wrong patient a standard dose of PO Tylenol. It was also a verbal order from a PA and he also told me Bed A when it was Bed B. I know I should have, but I did not report it. I was so scared to! It freaked me out enough to learn from it though, that's for sure! I have only been a nurse 4 years, but I'm sure it will happen again at some point (though I will try my hardest to not let it)!

    I think the physician should also be sat down and debriefed. Physicians have just as much responsibility to follow protocol and not expect anything to be given without a written order. Far too many facilities just don't do this and the issues will continue to happen, especially among new and easily intimidated nurses. It is both party's responsibility in a sense and he should be alerted that it happened. He needs to think twice before barking orders moving forward and realize mistakes happen and it's his patient too.

    Another anecdote - I worked with a doctor who literally yelled and belittled nurses, and I even witnessed him throwing patient charts on the ground! He was an absolute monster! He was leading a code and I noticed that the rhythm had changed briefly from asystole and he screamed "YOU DON'T KNOW ANYTHING, THAT'S JUST PEA!!" Sure enough, the patient's pulse returned shortly after that, though he went back into V Fib and ended up dying eventually. It made me so livid that he tried humiliating and dismissing me like that! Everyone has a voice, especially in a code, and everyone is an integral part of a team. Anyway, I reported the incident to my ADN, and he pretty much just kept his mouth shut for the rest of my working there. He was still unpleasant to work with, but he was no longer insulting, so I have to think someone sat him down and explained his behavior was unacceptable.
    Last edit by BklynHeightsRN on Feb 23, '17
  13. by   BklynHeightsRN
    Quote from Dragonnurse1
    I have taken orders for 2 beers with meals