Suspended for a Medication Error

[Nurse Beth]

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 on an orthopedic unit in acute care. I rounded with Dr. G on two of his patients... 2 elderly ladies in a semi-private room... the same semi-private room.

Suddenly, Dr. G got my full attention as he barked out an order in my direction "Change that D51/2 NS to D5W on Bed A." (My apologies for referring to patients by their bed assignment, but that's how it happened). At least that's what I thought I heard Dr. G bark... I mean, say.

I was eager to be competent and efficient. So before Dr. G had even returned to the nurses' station, I had the D5W in hand, ran in, took down the bag that was hanging, labeled, spiked and hung the IV. On Bed A... just like he had ordered. An expedient medical intervention by a skilled medical professional, Yours Truly.

I was proud of myself.

I was so wrong.

The Repercussions

My Nurse Manager called me aside later that day.

"I need to see you. In my office.... Now."

The tone in her voice and her words was enough to cause me great concern and anxiety. I had a sick feeling in the pit of my stomach. I followed her into her office unsure what was about to happen to me. She seated herself in her chair behind her desk, and motioned for me to sit across from her. I quickly noticed there was nothing on her gleaming wooden desktop... Except for a single piece of paper. I suddenly felt a sense of doom.

Without further ado, she informed me that I had administered the IV fluid to the wrong patient, which constituted 2 med errors. Apparently, Dr. G's orders read "Change the IV fluid on (Bed B) to D5W."

Uh-oh... So both patients had the wrong IV fluid. I felt faint as the blood drained from my face.

In addition, and most important, I had not identified the patient. She proceeded to inform me that I was on three days suspension without pay, and to clock out immediately. She pushed the disciplinary form across the desktop towards me for my signature.

As busy and short-staffed as the unit was, my mistake was clearly exceedingly profound, as I was being sent home mid-shift and was Banished from Patient Care for three days. I wasn't indispensable after all. Because I was Unsafe. I gathered my things and walked the Walk of Shame with my head down in front of my peers to the elevator. I drove home in the early afternoon on empty streets without traffic. Home to an empty house in the middle of my workday.

How Could This Happen?

We all know the 5 (6, 7, 8 and climbing) Rights of Medication Administration:

• Right Patient
• Right Drug
• Right Dose
• Right Route
• Right Time

So what had happened? How had I failed in something so fundamental? There are many things that contributed to my error. Here are three that I was responsible for:

1. I opted for speed over process and safety.

I took a shortcut by failing to check the written orders, note them, and identify the patient. Following the same process step by step without variance prevents errors. Like an airplane pilot. I learned an invaluable lesson well that day.

BE THE PILOT.

2. Ego. Pride.

I was eager to please and perform. To show everyone, esp. Dr. G, what a bright new RN I was. Because surely Dr. G was going to be impressed by how fast I could make his orders happen. Looking back, I'm pretty sure he was only vaguely aware of my presence at all, and the only thing that might have caught his attention was if I had hung that IV wearing a tutu while whistling Dixie.

3. Unintentional learning- maybe the most interesting.

I had been an LVN before becoming an RN. At the facility where I worked, LVNs did not manage IV fluids. So oftentimes I would be in the room and watch the RNs hanging IV fluids.

I admired their physical grace and coordination while nonchalantly flipping IV bags upside down, backfilling, spiking, reaching to hang....and I so wanted to be one of them! A bona fide RN with IV hanging privileges. But never in those scenarios I witnessed did the RNs ever check armbands for IVs. So the unconscious learning that took place...and that was indelibly imprinted...was that IV fluids are not medications! Crazy, huh? But that learning was exactly what happened...unintentionally.

Of course, in nursing school, there must have been that day where they said "IVs are Medications" Did I miss that day? Was I only studying to the tests, and not the real world? I don't recall. There's school learning and then there's real learning. How real learning takes place is another blog. As I'm an Educator and all.

How I Felt

Shock soon turned to utter devastation. I was on the crazy train. I felt shame, embarrassment. Confusion. I had always been the straight A student. Class President. Honor student. Failure and suspension were not me. I was one of the top RNs in my class. That person. Now, who was I? It was ego-shattering. My self-confidence vanished. Gone. Just like that.

Once home, isolated and alone, my thoughts collided. Were the patients harmed? Would I be fired? Was I forever marked? How could I ever practice nursing again? My emotions reeled. I pictured another RN going into my patients' room and fixing my error. Hanging the right IVs.

Making the mistake was one thing, but being suspended added gravity and shame. This was a felony, not a misdemeanor. I wasn't angry about the harsh punishment. They must be right. I was sick and humiliated. Alone, I curled up and cried, but there was only an hour before my kids would be home from school, and I had to put on my Mom face. Dinner had to be made, homework had to be checked.

Fortunately, the patients did not suffer any ill effects, but that was only luck, right? If I could do what I had done, I could make an even worse mistake, right? I could hurt someone. RNs aren't supposed to hurt people.

Added on was that I was a single Mom of three, and three days without pay was going to hurt. Although I'm sure that was the intent. The rationale being that if the punishment hurt enough, the lesson would be learned.

And finally... I wondered if I should even be an RN. Hadn't I just proved that I shouldn't? Which was confusing, a cognitive dissonance. I had spent 6 years studying to be an RN with unswerving determination and... I shouldn't be an RN?

My world did not make sense.

Recovery

I didn't need suspension. What I needed was counseling and support. Here's what MeNow would say to MeThen:

Quote

"Give yourself time, Beth. Time brings perspective, trust me. You don't know this yet, but every, and I mean every, RN makes mistakes. Welcome to the real world. Reality check- you are not perfect. You also don't know that you are going to be a gifted nurse. And go on to help a lot of people. Figure out what went wrong and learn from your mistake. Find someone safe to talk to. Forgive yourself."

And also from future Me: "Have a glass of wine. You don't know this yet, but a robust Cabernet is going to be your favorite."

I returned to work. From then on, I was obsessed with patient identification. Even if I was in the middle of a med pass, and turned around to grab a unit dose container of Milk of Magnesia out of the patient's drawer, and walked back to the bed...I re-checked the pt's ID. (This was before barcoding).

Time passed, and my shaky self-esteem began to stabilize. Eventually, the good days outweighed that one awful day, and my mistake was finally in the rearview mirror.

Was that my last medication error? Well, as any nurse knows, that's a rhetorical question. No, it wasn't. Making mistakes never got easier, but recovery happened faster. My ego was shattered, but when it came back together, I was more resilient. Healthier.

How did mistakes change you?

How did you recover?

I'd love to hear your feedback.

[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.

[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.

[BklynHeightsRN]

I have taken orders for 2 beers with meals

[oncnursemsn]

Thank you for clarifying- please go back and re-read the original post. This happened many years ago and she has gone on to earn her master's degree. I don't think those who wrote her up were bipolar or lying. I admit I'm distracted by difficulty getting through your spelling and punctuation but I don't want to distract from the original post.

[Orion81RN]

Thank you for sharing your story. In a sense, it was sharing OUR story as most of us have made mistakes that we have had to learn from and finally forgive ourselves for. I especially love how you later reflected and had a "talk" with the you then. I have been personally helped by your story. Thank you!

[angeloublue22, BSN, RN]

Within my first month of nursing in a psych facility I had 2 men walk up for their meds both with the same first and in the same room. I gave one the other's medication but caught it immediately so it was only one med error, thank goodness. I was so distraught and worried about the man but everyone was incredibly supportive. I asked if they wanted me to leave but my supervisor hugged me and told me to take it as a lesson, gave me time to gather myself and helped me monitor the client who suffered no ill effects. The next day my DON called me at home and I thought, "This is it." She then asked if I was okay and asked if needed anything because she had heard how freaked out I was. She then set up a counseling meeting with me to figure out how the mistake had happened. It was a relatively new hospital and all of the kinks still hadn't been worked out. After that we made it a protocol to never put patients with the same names in rooms together, if at all possible. I have to hand it to my supervisor and DON for the counseling. It helped me become a better and more careful nurse and it taught me how to be proficient supervisor myself. They handled it perfectly. I always say, "People don't usually make mistakes on purpose, they just need some effective teaching." I've never liked a punishing atmosphere.

[TexasBlue]

What comes out loud and clear is "Where is your mentor"? "Who are they, are they available to you? You should be scheduled with your mentor. Their job is to bring you in , teach you the ropes and be there for you. A good mentor would be having you run things past them before you act. Especially medications. Med errors are the worst. We've all been in that uncomfortable situation. Things are different now. I've never seen such stress and tension on the floor. Zero tolerance. No trust. What is happening?

I was lucky. I was scheduled with two experienced RNs. Everything was run past them. I was with them for three months. They saved my butt many times. They were kind, gentle and patient. I learned. A lot. Humbled. Lost the "new graditis" pretty quick. Learned confidence and became a good nurse because of them. And now... I am doing this for other new grads.

As it should be.

[Skippingtowork]

A very positive story and positive, uplifting comments. It is so sad that so many years later, we still have situations where mistakes are treated as crimes and not an opportunity for learning. We all have the same goals, taking care of and keeping patients safe. Those in authority often penalize nurses for errors, leading to a culture of cover-up. What's awful is physicians who contribute to medication or procedure error by not complying with policies, but are revered by administrators because they are seen as bringing money to the hospital. A physician who is rounding on patients on the floor, should not be giving verbal orders. There are few real emergencies. Get on the computer and enter your orders, then let the nurse know you have placed orders. Period. Charge nurse, support your nurses when they are confronted by ill-mannered physicians.

[RN2be_Tiffany]

Beth, thank you so much for this article! As a current nursing student who hasn't been in the clinical setting very long, I really found your story extremely reassuring and educational. Thanks to your story, I know I will NEVER take a verbal med order from ANYONE. I'm sure our facility policy, most likely, prohibits such orders, but as I said, I'm very green. I will keep your story in the back of my mind at all times. Thank you again.

[Ruby Vee, BSN]

Beth, thank you so much for this article! As a current nursing student who hasn't been in the clinical setting very long, I really found your story extremely reassuring and educational. Thanks to your story, I know I will NEVER take a verbal med order from ANYONE. I'm sure our facility policy, most likely, prohibits such orders, but as I said, I'm very green. I will keep your story in the back of my mind at all times. Thank you again.

Verbal orders aren't given or taken much nowadays, back in the day they were very common. It was the way we did things then -- not saying it was ever a good way to do things, but it was just the way things were done.

What the take-away these days might be is this: If you're helping out a fellow nurse by giving her noon meds or medicating her patient for pain because she's involved in a giant time-suck with another patient, don't just take her word for "2A needs his heparin injection" or "3B needs her dilaudid". Look at the MAR and make sure that her patient does indeed have heparin scheduled for now, whether it's SC or IV, the dose and his last PTT. Make sure you're doing the right thing. Assess her other patient's pain before you just rush in and give her dilaudid, then check the MAR and make sure it's the right dose, route, time, patient, etc.

If it's your own patient and new orders have just been given, make sure they make sense. I wish I had a dollar for every time a physician told me (or wrote orders for) a change in medication on Mrs. Thompson when he really meant his OTHER patient, Mrs. Thomas. If he's written for SC heparin on Mrs. Johnson when she's on a heparin drip, did he really mean for the SC heparin to be for her or for Mrs. Thompson, who needs orders for DVT prophylaxis? Or was he writing for Mrs. Johnson because he intends to stop the heparin drip? WHY is this order being given for this patient now?

The other takeaway from Beth's story (one of many) is that we ALL make mistakes. Every single one of us. You WILL make a mistake. Mistakes are inevitable. When you make a mistake, you are not alone. And just like the rest of us have had to, you will reflect upon your mistake, determine to do better and face your colleagues again. Eventually, you can forgive yourself. We all make mistakes.

[Cowboyardee]

Verbal orders aren't given or taken much nowadays, back in the day they were very common. It was the way we did things then -- not saying it was ever a good way to do things, but it was just the way things were done.

For whatever it's worth, I still see a lot of verbal orders where I work. How much doctors rely on verbal orders seems to be facility-specific. Of course, reliance on verbal orders are one more avenue for nurses to make medication errors.

If it's your own patient and new orders have just been given, make sure they make sense.

1000 times this. It's the main thing left out of the otherwise excellent OP, and the most important defense against medication errors that seldom gets discussed. Don't perform orders until you understand the rationale for them. Make exceptions in an emergency if you have to, but as a point of safety and general discipline, flying blind is terrible policy. Understand what you're doing before you do it whenever possible.

[Tooda]

Medication errors can be fatal. You being a new nurse the 5 rights when giving meds should be fresh. You also have to be mineful when giving meds there should be no distractions, stay focused and double check yourself. I remember working on a med-surg floor years ago and a nurse hung Pitosin on a male patient, she to was a new nurse but clearly should have known that the drug was incorrect and given to women. If you have learned from your mistake it will make you a better nurse