I feel awful, it's three months into my first job and I gave a patient a much smaller dose of tinziparin than was prescribed. I didn't realise until the next day when I went to give the same mediciation and noticed the dose. I filled in an incident form and documented it in the notes. He is on warfrin too as he's had a PE before coming to the ward from HDU, his INR had still come up the day after than it had been the day before. I'm horrified about what will happen next, if I'll be in trouble, if the patient will be ok. It's totally my fault, I must have checked the wrong chart as I'd looked a few out that needed this medication. Theres no excuse for it and I blame no one but myself, just can't get my head around how it went wrong. I feel like the worse nurse in the world, and I'm doubting that I'm cut our for ward work since I can't even last 12 weeks without doing something so silly.
Jan 18, '09
Think about it for a minute. How many nurses are handing out how many meds two to three times a day, and then ask yourself how many medication errors (including those that are never discovered) are made every day. It must be thousands. And out of those thousands how many patients are seriously affected? I'm guessing next to none or we'd be reading about it every day in the papers.
The important thing is you did the right thing by reporting it, and even more importantly, you will learn from it.
Don't worry, and don't beat yourself up about it.
Jan 18, '09
First of all, I don't think you'll get into trouble, as there is a "no blame" culture in the NHS now more than ever. At most, you may have a ward manager speak to you to see if there's a way to avoid a similar mistake happening in the future. Your Trust shouldn't be looking for someone to blame but will likely seek to learn from the mistake. You did the right think by filling in the incident form, and it doesn't seem that it was an adverse event (probably not even catagorised as a near miss), so try to relax and chalk it up as a learning curve.
Jan 19, '09
Thank you for your replies. I do feel much better now. I called work and made sure the sister had got the incident form, and she's read it now and told me not to worry about it and she'll deal with it tomorrow. It's my third incident form now in 3 months, ouch. First one was because i didn't give vancomycin as i couldn't find it anywhere on the ward and since it was prescribed the day before we figured it wasn't ordered, turns out it was in the CSSD room all along. Second was because I didn't give a medication that I hadn't been told was precribed, no biggie, but I did an incident report anyway just incase anything came up about in down the line. So I'm praying that these things come in threes, and ONLY threes.
This one is the first one that I feel I'm really at fault, and I am. It's a massive learning curve for me and I'll never ever not second check a dose again.
Jan 20, '09
Sunshine if you've had 3 drug incidents within a short period you may well find your manager asks you to attend extra training and further assessment, this is what we do. Check you drug error policy it should be explained there.
Manda is right that the NHS has a no blame culture but if there are a few errors then training needs will need to be looked at to make sure your getting the support and training that you need
Jan 24, '09
i thought the NHS had a limited blame culture following shipman so our pharmicst told us during percetorship training.
And my ward is getting very strict on gaps in drug cards or not documenting why a drug was omitted for whatever reason we have to use the omission numbers and inital each time. what gets me is translating doctors handwriting or drugs and doses, i grab the nearest nurse to confirm. oh and missing a drug ordered not sure what your drug cardex look like but stat doses are on the front(leaf) of our 3 leaf cards, then i check all te regualr timed drugs area.
Last edit by ayla2004 on Jan 24, '09
: Reason: imcomplete
May 26, '09
Anyone who's never made a drug error is a liar. As long as you admit your mistake and learn from it, it's ok. Ultimately the pt came to no harm. It happens, don't beat yourself up about it.
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