Suspended for a Medication Error

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    My story of being suspended as punishment for a medication error. It was traumatic.

    Suspended for a Medication Error

    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 in to 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:

    “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 Cabarnet 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 bar coding).

    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 rear view 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.
    Last edit by tnbutterfly on Feb 21
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    Nurse Beth has '20+' year(s) of experience and specializes in 'Med Surg, Tele, ICU, Ortho'. From 'Bakersfield, CA'; Joined Mar '07; Posts: 1,013; Likes: 3,101.

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    50 Comments

  3. by   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.
  4. by   Tweety
    Pretty much all of my life's lesson's be it in nursing, or outside in the world, have come through the school of hard knocks and mistakes. I'm a stronger and better person because of them.

    I am not my mistakes.
  5. by   3ringnursing
    Oh Beth. This article is beautiful, in a scary messed up way, because we all have been there, done that. The eloquence of the way this went down paints a very vivid picture. And I think I am safe to say we all have been there.

    Suspension is just wrong in this instance - how else do we grow from our mistakes without punitive repercussions. But as I was often reminded as a new nurse, the Board exists to protect patients, not nurses.

    I hate to admit even worse happened to me as a new RN. The Walk of Shame is one I recall well 23 years later. If I live to be 200 years old I'll never forget it. And my husband was not the forgiving sort, heaping even more burning coals on my head then I had already placed there myself. I wondered if I would even have a license after my fiasco. Mine started as a new RN, new mother, and unexpected death of my own mother - all within 3 months. I fell far from grace into an abyss of shame and self loathing. Your story rang oh so true through the intervening past 2 decades.

    I still bear the scars to this day, although those I work with closely have no clue for the source. Whenever my supervisor (a lovely woman) wants to talk to me I still shout in my head, "What did I do?".

    Important lessons in nursing can hurt deeply, even though the repercussions of an error could be fatal. That's a lot of pressure for us all, new to the profession, or old hats. We as nurses bear a huge responsibility that grows ever more encompassing on a daily basis.

    Thank you so much for sharing Beth.
  6. by   Libby1987
    I didn’t need suspension. What I needed was counseling and support. Here’s what MeNow would say to MeThen:

    “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.”
    This really resonates with me, makes me tear up actually. When I made my med error, hung blood with D5W convinced that I understood the rationale and therefore didn't confirm with the P&P, I was pretty discouraged with myself. I was also very young and emotionally immature. I couldn't see my future self, that I would go on to be very happy in a long home health career, that I would touch many lives in such a good way, that they would in turn touch my life in such great ways. If I had just known that, I would have known all that I had to look forward to. As it were I had youth and resilience on my side and survived my big fail. And it was my fail in my case, not the system's.

    I'm reminded of this when I'm hands on in the building of a new nurse. You never know what jewel lays beneath and what their nursing life will look like one day but I imagine there's a world of possibilities and I hope my words are the right ones.

    And also from future Me: “Have a glass of wine. You don’t know this yet, but a robust Cabarnet is going to be your favorite.”
    This was another most wonderful completely unexpected surprise!
  7. by   traumaRUs
    Great article. Thanks for sharing.
  8. by   azhiker96
    My first Med error happened during orientation to PACU. I had become competent with adults and knew the standard order of ondansetron 4 mg prn n/v. I started working with pediatric patients and had a child get nauseated. I went to the Pyxis as I asked my preceptor to see if I had an order for zofran. He said I did so I deftly filled a syringe and administered 4 mg of zofran. Then I looked at the order and my heart sank. It read 2 mg instead of 4.

    Omg, I had made an error and on a child! I called anesthesia who said it was okay but not to give any more Zofran. Still, it stuck with me and made me double and triple check orders and vials for several years.
  9. by   marcos9999
    One time Dr X barked some orders so fast over the phone I wrote it down as well as a could. After he finished I asked if he could go over them because I missed or wasn't sure of a few items. He barked at me saying that I was incompetent. Orders not taken, wrote a note. Dr unable to clarify orders, orders not taken. End of story. So the lesson learned is: until you have a complete order that is clear concise. DON'T GIVE ANY MEDS. You'll never get into too much trouble for not given a med because you're enable to clarify (given is a real reason). But given a wrong order is like running a red light.
  10. by   Nurse Beth
    Quote from 3ringnursing


    I hate to admit even worse happened to me as a new RN. The Walk of Shame is one I recall well 23 years later. If I live to be 200 years old I'll never forget it. And my husband was not the forgiving sort, heaping even more burning coals on my head then I had already placed there myself. I wondered if I would even have a license after my fiasco. Mine started as a new RN, new mother, and unexpected death of my own mother - all within 3 months. I fell far from grace into an abyss of shame and self loathing. Your story rang oh so true through the intervening past 2 decades.

    I still bear the scars to this day, although those I work with closely have no clue for the source. Whenever my supervisor (a lovely woman) wants to talk to me I still shout in my head, "What did I do?".

    Important lessons in nursing can hurt deeply, even though the repercussions of an error could be fatal. That's a lot of pressure for us all, new to the profession, or old hats. We as nurses bear a huge responsibility that grows ever more encompassing on a daily basis.

    Thank you so much for sharing Beth.
    It's really traumatic and something that stays with you, even though we grow from it- we don't forget. Thank you for sharing
  11. by   FutureNurseInfo
    What a wonderful read it was! I could truly feel the pain and anguish you experienced! Thank you for such an insightful article!
  12. by   sassymulassy
    Thank you so much for sharing your story. As a brand-new RN about to start my first job, I am very nervous about making mistakes. Your advice was great for me to hear and helped me feel better about the need to take my time for the important not-so "little" things (patient identifiers, verifying orders) rather than try to be just like the experienced nurses or prove how competent I think I am. Thanks again!!
  13. by   JayHanig
    God, I'm so glad I'm retired and don't have to put up with this crap any longer. I've been called into he office over mistakes like this; even got fired once for a similar thing.

    At the point where I retired, I'd not been written up in seven years. Had I become the perfect nurse? Hardly. I was a better nurse and made fewer errors, true.... but I also became much more skilled at covering my errors up. As punishing as nursing is, why give them any ammunition? Let them catch what they can but short of risking a patient, don't hand them the rope.

    Technology has made it easier to prevent your error, even in a hospital as behind the times as my last one: you could not get a a bag of fluids until the pharmacy made it available to you in the Pyxis. That meant the MD had to actually write the order, it had to be translated into English by somebody who could make it out, then it had to be verified after computer entry that it'd been seen by you. Only then could you get the new fluids. So take a deep breath the next time and unless it's a code, there's no rush.

    I will say that considering your status as a new RN, your manager is a *****. I'd find another unit if I could. Your current manager will stab you in the back at the first opportunity. Why did she jump so hard on you for this mistake? To protect herself from criticism.

    Your mistake rated a quick talking to and no more. The manager screwed the rest of her unit by short staffing them for three days. Did she step up to take your place on your Day of Infamy? You can be sure she didn't; she just dumped it on the rest of the staff: "Work smarter; not harder." echoing in their heads.

    You have my total sympathy and I hope you will seriously consider moving to another place ASAP. If she's already given you a three day suspension, the next error is likely to cost you your job. Trust me, there are crappy nurse managers that are better than her.

    Leaders motivate by making people want to please them and not disappoint them. Yours motivates through fear. That's one way to guarantee getting the bare minimum out of people and having nobody willing to back her when she finally gets into a pinch herself.

    The manager who fired me after my med error? I understand she was led off the property by Security, not even allowed to pack up her office. Instead it was done for her. I was so sad. It seems nobody would back her in her time of need. Golly.
  14. by   Makaiah123
    Thank you!! What an amazing story. We're are not perfect as nurses and as people. We make mistakes. And you do have a gift. Its called being humble and forgiving yourself. And that word resilience was my favorite in lvn school. It means no matter what life throws at you , you get up dus yourself off and you fight!

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