Have you ever made a med error? - page 3

i'm a senior rn student & i made my first med error last week. the nursing director said if i make another med error i'm out of the program. Has anyone done a med error as a student? i know i'm... Read More

  1. by   WhoMeaNurse
    True, listen to the patients.
  2. by   traumaRUs
    I wish you the best of luck. I personally know of no nurse who hasn't made a med error.
  3. by   RN1263
    Quote from traumaRUs
    I wish you the best of luck. I personally know of no nurse who hasn't made a med error.
    Thanks!...I have found that lay people just can't understand how a med error can happen. Their like... "wwhhhaatttt????!!!!".

    So, this board has helped me talk through the shame of it & get on w/ my life!
  4. by   hica19
    I have never made a serious med error, but I did make two really small ones. I mean I did the 5 rights and they were fine. However when I was giving an IV med to a pediatric patient, I was trying to work at the speed of an experienced nurse. I ended up dropping the med in the wrong buretrol. It was all good though because at least the fluid in the buretrol I dropped the med in was compatible with the med. I just had to make the extra step to switch the lines. And then another minor mistake I made was when I was giving flagyl. It was to the same patient. this time I dropped the med in the right buretrol. However, I accidently filled up the buretrol with fluid with the med already in. So becuse of this, I had to run the med over 2.5 hours instead of 1 hour like it was supposed to. My word of advice...follow your lines carefully! It will save you a lot of time and trouble!
  5. by   rags
    Quote from firstyearstudent
    I made a med error once. Along with the tablets/pills in blister packs was a little labeled packet sent up from pharmacy with 6 pills in it. The label gave the dosage and the patient's name. When I went to give it to the patient he said, "This looks like a lot of of these pills. More than I usually take." I said, "It's fine, my instructor and I double checked it." But we both just checked what was written on the label. We did not count the pills. So he just took the pills. (My instructor went into the room with me, but left to take a call giving me the go ahead to actually give the pills.) Later I thought about what he said and realized that pharmacy had sent up the whole day's dosage in that packet. He should have taken three pills BID. I thought about whether I should say anything or not and then figured I should 'fess up. I told my instructor and she did not fill out an incident report or mention it again (my suspicion is not only because it was only a fairly harmless supplement, but because she had double checked it and then left me in the room by myself). She also told me not to tell anyone. So, anyway, what I learned is that if a patient questions their meds -- TAKE IT VERY SERIOUSLY AND DOUBLE CHECK!!! I also learned that if your patient is taking more than 1 or 2 tabs of something RECHECK the dosage carefully and figure out why that is. There should be a good reason since most tablets are formulated for the typical dosage. (This happened to me today when my patient had 7 tablets of the same drug -- however, it checked out. Too may pills is a waving red flag for wrong dosing.)

    I also learned that instructors are quick to make students take responsibilty, but not so quick to take it themselves...
    In my opinion your instructor should no longer be instructing. She not only broke the rules and put your future license on the line by leaving the room and giving you the "go-ahead" (in my state giving medications with out a license or supervision by a licensed person before you are allowed can keep you from receiving your license when you apply later. In fact a work with a person who has passed the NCLEX and is waiting for the board to meet so they can decide if she can be licensed for just that reason)... sorry let me finish that sentence now... and giving you the go-head... then NOT filling out an incident report and explaining to you that the MD also needed to be notified of the med error was mal-practice. At least that is my
  6. by   rags
    dijmart ~ I made a med error while in nursing school. I had two pt's in side by side rooms with similar names (something like: Margaret and Martha...) and the same last initial. To help make matters worse they were also both TKA's and on similar meds. actually at noon the same meds different doses. Well, to make a long story short (if you can't see it coming already) the Coumadin they were on was the same tablets but (say Martha) required me to cut hers in half and waste the other half of the pill. The RN's on duty were (as others have mentioned) anxious to get to the pixis and there was a line of students waiting to pass meds with my instructor so we both rushed a little and I forgot to cut the pill before admist.

    This was not a 'critical' mistake and there was no harm done, it most definitely was a devastating experience for me. Had I taken the time to check the MAR one more time (I DID my 3 checks, but should have done 4 under the circumstances ~ two pt's with similar names, same Dx, same meds, etc...) I would have noticed the error BEFORE it happened! I took FULL responsibility for my actions. I was the acting 'nurse' and it was MY responsibility to make sure my pt's received competent care, which in my opinion due to the error, they did not. We filled out an incident report, monitored the pt and reported it the DON of the hospital as well as the pt's Dr and the director of the nursing program at my school.

    Unfortunately there is NO excuse for making a med error. There may be contributing factors but never any excuses. The person handing the patient the medication is ultimately responsible for the accuracy of it. IMO.
    Last edit by rags on Oct 16, '06
  7. by   mitchsmom
    I made a med error in school and the pt was fine but it was sickening for me.

    I won't go into details but it was one of those "chain of events" errors with multiple things leading to it (I repeated a med for a pt who had already had it - the previous nurse didn't chart it, among numerous other problems in the chain of events - my instructor did the whole thing with me and didn't catch it either).

    edit to add:
    Unfortunately there is NO excuse for making a med error. There may be contributing factors but never any excuses. The person handing the patient the medication is ultimately responsible for the accuracy of it.
    I do agree with this, which is why it was so sickening for me and it still makes me sick to think about it.

    I guess it was good for making me even more alert to meds than I already was; even now I always check things a million times because I'm so paranoid still (I graduated in May and have been working 3 months). As everyone said, use it as a learning event, that's really all you can do. It's just one of those thing that there is no wiggle room in. ((hugs))
    Last edit by mitchsmom on Oct 16, '06
  8. by   sungoddess
    Sorry about your med error..... it is a tough way to learn something VERY important.... Remember SOME MISTAKES can NOT be corrected, this is so true with medications....... Yes I have made a med error, and I believe so has EVERY other nurse out there....... in nursing school I drew up insulin to give a patient, my instructor asked me are you sure your ready to give this? I stated "oh yes" ( oh no wrong insulin)... she let me walk into the patient room right up to the patient wipe with alcohol wipe and then stted " would you step outside the room" and then the instructor took me back to the med room and handed me the bottle of insulin, it was REGULAR not 70/30.... I CRIED, I was so afraid that I almost killed a patient. ( or thought I had)... this was very tramatic for me.... My instructor was great, and what a lesson. To top it all off my grandaughter who had turned 3 yrs old the prior semester had died of a med error in childrens hospital in so. calif. given another childs medication, she had a seisure and died. HORRIBLE....... PAINFULL.....and can not be corrected....... I am so careful with my medications with my patients. always remember some mistakes can not be corrected..... Hang in there...Bellaluna LPN (hopefully soon to be RN)
  9. by   Pheebz777
    A better question should be:

    Who hasn't made a med error?

    I would be impressed...
  10. by   kukukajoo
    We start passing meds in about a month and I just want to thank you all!

    First, these posts help me to realize how easy it is to make a mistake and how very very careful one needs to be.

    Second, If and when I do make that mistake I hope and pray it is a small one and not devastating to the pt.

    Third, I pray I remember not to crucify myself over the mistake. I am sure this last one, though!!

    Thanks for showing 'this' student everyone is human!
  11. by   RN1263
    Quote from kukukajoo
    We start passing meds in about a month and I just want to thank you all!

    First, these posts help me to realize how easy it is to make a mistake and how very very careful one needs to be.

    Second, If and when I do make that mistake I hope and pray it is a small one and not devastating to the pt.

    Third, I pray I remember not to crucify myself over the mistake. I am sure this last one, though!!

    Thanks for showing 'this' student everyone is human!
    looks like you were able to learn from this thread, so i'm glad i started it. of course, i had my own agenda at first, but then realized it was helpful for everyone! good luck to you & like everyone has said just be VERY careful & aware of what is going on around, you so you aren't distracted.:wink2:
  12. by   Kelly_the_Great
    Quote from Pheebz777
    A better question should be:

    Who hasn't made a med error?

    I would be impressed...
    Okay, here's another question..."how many med errors occur that go undetected?;" meaning not just that they aren't reported or what have you but that they're never caught in the 1st place?
    Last edit by Kelly_the_Great on Oct 18, '06
  13. by   sulynn1955
    In nursing school, one of my instructors told us that any nurse who says she hasn't made a med error is a liar, and I believe that's true. I did, in fact, make a med error in nursing school. I had a patient with seizures. At that time, on the MAR, you had squares underneath times and you checked off meds you gave at specific times. I saw an antiseizure was to be given and gave it per G-tube. I failed to notice that the one dose was to be held and it was too late, I'd already given it. We called the Doc, he said to monitor the pt and everything was fine, but it scared the heck out of me. Another student made a mistake when she went in to give insulin and asked the pt if he was Mr. Jones and he said yes. She gave him insulin, only to discover he was confused and he was not Mr. Jones, and not diabetic! Of course, the Doc was called, the pt was monitored, blood sugar checked and he had a meal and he was okay too. Passing meds is a huge responsibility, so try not to allow yourself to be rushed which is tough when you have a ton of patients, but you have to make yourself follow the 5 rights, all the time. As others have said, learn from your mistakes, I know I did!

close