Suspended for a Medication Error - page 4
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
Feb 24, '17Thank 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 yourand punctuation but I don't want to distract from the original post.
Feb 25, '17Thank 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!
Feb 25, '17Within 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.
Feb 25, '17What 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.
Feb 26, '17A 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.
Mar 6, '17Beth, 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.
Mar 6, '17Quote from RN2be_TiffanyVerbal 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.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.
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.
Mar 6, '17Quote from Ruby VeeFor 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.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.
Quote from Ruby Vee1000 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.If it's your own patient and new orders have just been given, make sure they make sense.
Mar 8, '17Medication 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
Mar 12, '17I agree with you that you shouldn't have been suspended. There were three victims in this incident, the two patients and yourself and too many times people forget that the nurse themself is as much a victim as the patients. You are the one who is going to carry this mistake with you for as long as you live and it will never leave your mind. It will make you a better nurse because this is something you will NEVER want to experience again. I know this from experience. I made a med error and years later I still am scarred by it because I know what could have happened. That initial moment when I realized what I had done was THE most traumatic moment of my life. It was a lethal mixture of fear, shame and self loathing. Those calls to the doctor, the patients family and my DON were so hard. I didn't sleep at all that night and I pestered the poor night nurse with at least a half dozen phone calls to make sure the patient was all right. She was fine but it didn't make me feel any better. It sounds like you are a good and honest nurse know that this will get better and it will make u a better nurse
Jul 27, '17Im a new nurse working in a critical care/tele/stroke unit. I love it. Truly, this is my calling.
Last night at shift change i received a patient from ER. The nurse on the previous shift took report but I was the one to received the patient. Took one look at him and walked quickly to my charge. Report said he had a 98.1 temp. I got him at 102.8, uncontrollable chills, an unreported cather sticking out of his neck. Told my charge of the situation. We called for motrin and a cooling blanket. Temp is now 103. The doctors, arnp, and pharmacist are going back and forth about the vanco because he has ersd. Doctor comes bedside and states he looks bad (her speech was way more illuminated than that but that was the gist of what she was saying). I thanked her for confirming what i initally said. She was pretty awesome. 3 hrs later he was finally moved to icu with a 104.3 rectal temp. It took another 3 hrs for them to get his temp under control.
What i worried about all morning after i left work was not checking the compatibility with d5w, zoysn, and vanco.
So my point of this long winded story was I had 5 patients that night. I was told by one he was writing a letter about me because what amazing care i gave him. I had another patient who use to practice nursing tell me that i chose the right field of acute bedside nursing. That I had a way with patients that most people dont. Also had a confused patient that me I was the sweetest nurse he ever had.
But I dwelled on something that may or may not have been a mistake and if it was a mistake, the patient was okay because i checked on him 4 times after hanging those antibotics....
I will always check comparability. ALWAYS
So I thank you for this article. I am really hard on myself. Harder than any write up could ever be. I am a nurse and I want to protect and care for my patients. I feel horrible when I think I failed them.
Sep 2, '17I was a young LPN basically fresh out of school and handed an entire Assisted Living Unit to run. I was eager to please, prove my worth.
Until IT happened.
I was in the locked Alzheimer's/Dementia unit one night when a patient fall occurred on the regular unit. About 90 minutes later I was informed of the fall and also that the MD had been contacted. And THEN this CNA/Mes-Tech had summarized the conversation with the MD to say that, "we don't have a nurse on the unit."
I saw red. But I put protocols in place. I called back the MD, took the necessary orders, and then - delayed the XRays until the AM at pt request.
I own my mistake. I was also terminated the nezt work day I had. But I recovered and am now transitioning into a new and amazing job.