Two med errors... I'm sick!

Flare, ASN, BSN · Oct 12, 2011

ok... breathe.....

Mistakes happen. We are human beings, not machines. Take your errors and learn from them; use them to make you a bit more cautious and more attentive to details. Also - I don't know that i'd really get too bent out of shape over the ativan issue. In time you will know what dosages the pills come in - sure, it makes in a pain in teh butt for someone who may be giving 0.5 mg doses of ativan, but you did get your "right dose" requirement filled with your combo. The coumadin is a bit of a bigger deal, but you just inform the doc right away and fill out your IR.

You are not the first to have a med error and you will certainly not be the last.

**NickiLaughs, ADN, BSN, RN** · Oct 12, 2011

The ativan dose is not a true med error, correct dose was given. It just didn't meet their procedure requirements. Whatever, they really couldn't count that.

Coumadin was a med error, but it happens. Just watch patient for signs of bleeding and report it to the physician.

You will learn from it. Honestly, I think it's almost better to have a small med error such as that which will give you that extra feeling of caution instead of where your mixing a drip and realize it's the wrong med or the wrong concentration (have done that, thankfully caught it before I hung it).

We're human, and as nurses I think sometimes we feel we should be the robots management wants us to be.

TonyaM73, ASN, RN · Oct 12, 2011

Don't worry! Everyone feels this way at first. You have the realization that "these people's lives are in my hands!" and it is scarry. The coumadin thing sounds like a proceedure error. If it is a written MAR then the days that it should have been given should have been X out for you, so there would be no question that you should give it. Incident reports are there for good reason to find out how the process failed. You will learn the ins and outs soon and feel more comfortable. Good luck to you!

Maybe suggest to your DON that the days are Xed out to avoid this mistake in the future.

LaughingRN · Oct 12, 2011

I fail to see how the Ativan was a med error :)

You had the 5 rights....Given two pills instead of one to accomplish the same goal is not an error, possibly an inconvenience to someone (but I can't imagine who)

The coumadin was an error, but you took responsibility immediately. Perhaps you can be part of a system change to make sure similar errors don't happen, an arrow on the date doesn't sound too clear cut to me.

beatrice1 · Oct 12, 2011

I guess I shouldnt say it was a "med error" but it was carelessness on my part because I didn't see the 1 mg card there. I'm just doubting my "detail oriented" skills I guess.

morte, LPN, LVN · Oct 12, 2011

I just got off orientation (10 days LTC). It was my second med pass on this floor. I don't usually work on this unit, and it was only my 2nd med pass alone since off of orientation.
I gave Coumadin to a resident that was on hold untill the next day. I didn't realize the arrow was pointing to that date. I realized when I went through the book later to make sure I signed everything off. I informed the supervisor on at that time. (3-11) She had me fill out an incident report.
During the narc count, the oncoming Nurse realized I gave 2 0.5 ativan instead of 1mg. I did not see the 1mg card. I know she got the right dose, but it was another careless mistake on my part.
I am sick to my stomache, did not sleep all night wondering If I screwed anything else up. I am going into the DON to talk to her today and make sure everything is okay. Am I just new and inexperienced or just plain careless. Everyday I go in wondering If I am fit to be a nurse, I feel like I do not know anything. So afraid I'm not going to know what to do is something major goes wrong. I am so sick over this.
How do you know if you are really cut out to be a nurse? Maybe I'm just not compitent enough. I don't want to put anyone else in danger.
cd
Thanks for listening,
Bea

Your experience is the classic case for NEVER putting a med on "hold". It is supposed to be dcd, and reordered.

metfan · Oct 12, 2011

I worked in LTC before getting my RN and I can tell you that med errors often happened on hold meds. Because we used paper emars, it was easy to miss where the arrow is especially at the end of the month when you have to follow it to the edge of the sheet. When I got an order to hold a med, I liked to put an arrow but also a post it stating the order and the hold date. The post it was just easier to see and drew you attention to the hold order. Don't sweat the error. We are human and mistakes happen.

J-NO · Oct 12, 2011

Med errors happen, be thankful that it wasnt something like giving insulin to a non diabetic. Remember that the only one that judges you is you. I'm not even a nurse yet but, I do know that a good nurse is human. If you are accountable you an excellent nurse

nyrn5125 · Oct 12, 2011

ltc is different so I can only comment from acute care. The ativan is not an issue. The coumadin should have been blocked out by the word HOLD by whoever it was that picked up the hold order. This is how med errors happen. By not being specific enough. When giving meds, and obviously there are lots in ltc, you shouldn't have to worry about arrows pointing at something if the box was open we all might have given it.

J-NO · Oct 12, 2011

Im currently doing my 2nd clinical in LTC and I have already realized that LTC is a horror show. So many casuals, so much missed communication; botched orders etc.

xtxrn, ASN, RN · Oct 12, 2011

Don't beat yourself up :) Everyone makes mistakes, and as the others have said, the Ativan is a technicality...you gave the right dose. With the Coumadin, ok- yeah it's a mistake- but it also takes a few days for dose changes in Coumadin to catch up....nothing immediate is going to happen, and if the INR was really high, there would have been a vitamin K order.

Learn and move on- you're going to be fine. The fact that you care speaks volumes :)