Suspended for a Medication Error

Nurse Beth, MSN

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.