Made med error last night

[OgopogoLPN, LPN, RN]

One of my residents was getting a hydromoph 4mg, clonazepam .25mg at HS.

I gave her meds to her and went on to the next resident who was getting a codeine 30mg. My codeine 30mg was one short!! (I noticed this BEFORE I gave to this resident). I just about had a heart attack. I summoned the other LPN and we went through my cart thoroughly. We then counted all my narcs against the narc book and I was a hydromorph 4mg over the count. So, I had given the first resident a codeine 30mg instead of a hydromorph 4mg. THANK GOODNESS this resident was not allergic to codeine!!!!!!

I ALWAYS count my narcs in the blister pack before putting it in the narc book with the one I took out and signing for it. I just don't know how I made this error. Plus the fact that the cardboard on the codeine blister pack is white and on the hydromorph 4mg is bright yellow .

We summoned the RN on duty and she was very supportive of me. Thank goodness. I was close to tears as it was. I assessed my resident and she was fine. I had to do an incident report.

I know we're only human and make mistakes, but still. I just know I'll be 10 times more careful in the future. I've never been out one pill on any of my narc counts up until now.

[ohmeowzer RN, RN]

this will just be used as a learning expirence....you learned from it and it won't happen again... give yourself a big hug and not to worry..

you were honest about it and i send you kudos for that.. you did the right thing and you handled it well... it's okay baby... you are fine

[Turtle in scrubs]

I'm sorry you experienced this. Thank you for sharing as it is a good reminder how easy a mistake can happen with any of us. It is so hard to be "10 times more careful" when there are so many distractions and so little time.

Sounds like you handled the situation well, and I commend you for stepping back and taking a thorough account of the situation. :icon_hug:

[linzz]

You are not alone. I gave someone the wrong narcotic once. No harm was done but I felt like my world was going to end at the time. You did the right thing by being honest and that says good things about the kind of nurse that you are.

[Manderlay, MSN, APRN]

Yes, your actions after the event speak volumes about your character. You are going to be one great nurse.:heartbeat:redpinkhe

[pielęgniarka, RN]

Scary stuff. I know a nurse many years ago that inadvertantly gave a large dose of Oxycontin-- to a resident that had never been on narcotics! It was a terrible situation to hear about-- proper protocol was followed but the resident was not able to rebound and ended up passing away later that month. I never did hear what the family thought about it or anything, the res. chart was closed and it was hush hush. State did drop in for an inspection.

[CapeCodMermaid, RN]

We are human. Until someone invents a computerized nurse to give meds, there will be med errors. We have all made them and if we pass meds, will most likely make more. You did the right thing and your patient is fine. In the end, that's what matters.

[eldragon]

It is wonderful that you were honest and followed through with the incident report, taking responsibility.

I almost panicked once when I thought I may have given the wrong patient oxycontin, but luckily it turned out the correct med was given to to the correct resident.

Its great that you have support where you work. At the facility I work at, the QA/Infection Control Nurse is a pitbull (without lipstick) who would hang a nurse for such an error. Her attitude makes it highly unlikely that anyone would come forward and be honest about their error.

Where I work, you can deny anything and be left alone or admit you are human and pay dearly. Most people figure that out very quickly.

Once I stuck myself with a dirty needle and that same QA nurse made my life a living hell. As if I did not worry enough about what might happen, she rubbed it in my face that I could, down the line, be diagnosed with hepatitis and/or HIV. Luckily all the tests on me and the patient came back negative.

But that nurse who criticizes honestly and makes you regret coming forward to help a patient when an error is made, ultimately does more harm than good.

(She even told me once that, if she ever found out I knew someone else had made an error and did not tell her, she would suspend me! Now, that would be kind of hard to prove, right?)

So kudos on taking the right action to help the patient!

[linzz]

Your QA nurse sounds like a nightmare who is certainly creating an unsafe work environment. That is very sad when errors get covered up.

[southernbeegirl, BSN, RN]

Your QA nurse sounds like a nightmare who is certainly creating an unsafe work environment. That is very sad when errors get covered up.

I think i'd be looking for another job!

I made an error recently. I wrote a telephone order for a med as po instead of per tube. The nurse gave it po. The pt ended up in the hospital a week later with aspiration not caused by that one dose but it hurt me all the same. when my boss showed me what i had done, i couldnt help it and i cried just thinking i hurt her. I'm lucky i dont work with that QA nurse in the other post huh? lol

I think you did the right thing in the OP. Med errors never get easier to take but remember you are human and they do happen. All you can do is learn from your mistake and move on.