Med Error

Specialties Med-Surg

Published

Specializes in tele stepdown unit.

I feel really bad because I gave someone Lantus 100 u sq and through later detection it wasn't ordered. When I first saw the order listed on the MAR I questioned it. I looked in the chart for the order and did not see it. I called pharmacy and was subsequently sent a copy of original order with the patient label attached. I asked the pharmacist whose name I do not remember :uhoh3: (learning lesson) if this was a large dose. It was within the dosage range, but on the high end. I checked the dosage range myself within the pharmacy website. and the pharmacist was right . I am thinking that the original order was lost, which could happen . I administered the med and hours later during reconciliation of meds another nurse noticed the same order with the same handwriting on another patient . We compared the orders and it was the exact same handwriting and signatures. We beleive someone sent the order down to pharmacy with the wrong name label attached. :uhoh3: I fillled out a incident report and notified the dr. and supervisor which didn't go over well. I should have called the Dr. but when I did notify him after the incident he was also confused on which med the pt was on.

I feel bad because this means I am not a safe and effective nurse I will probably be written uo for this incident. :crying2: Also the reconciliation process the night before may have caught this error. There were other drugs on the order sheet the pt should have not recieved. When I left in the am the pt bs was in the 130's range.

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Specializes in CCRN, CNRN, Flight Nurse.

One error does not a bad nurse make. You caught the mistake and owned up to it. It is not fun when you have to write yourself up (been there, done that :o - my goof was very similar to yours). I wish I could say all nurses are perfect and don't make mistakes, but we all know no one is error-free.

I know you feel horrible about the situation (I sure did). Use it as a learning tool. You know where you made the error and I'd bet a shiney new silver dollar you won't make it again any time soon.

You were right to question something you thought wasn't correct. Continue to do that. Always remember to verify the 5 rights - especially when you don't think something is correct.

I hope this doesn't come across as harsh or disjointed sounding. I'm in the middle of a very long, very boring night :yawn:.

Keep your chin up. You'll make it!!

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Specializes in private duty/home health, med/surg.

Starcandy, I really don't see how this med error was your fault! You did what any reasonable nurse would have done. You did a lot of questioning and got the "correct answers" before you actually administered the insulin. Once you discovered what had happened, you filed the incident report.

Don't beat yourself up over this! Hopefully they will track down who originated the error.

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Starcandy, do NOT beat yourself up. I was in the same situation as you once. I think I was three weeks into orientation on night shift, staffing was very bad that week, and I was given my own patient assignment without a preceptor. It was a rough night and I made an error involving insulin. I totally beat myself up about it. But nurses are not perfect, we make mistakes too.

I think you did the right thing by following up with everything, contacting individuals you should've contacted, and knowing the blood sugar shows you monitored the patient a bit closer after realizing the error. You also followed through with an incident report, which I've seen many many nurses "forget" to do.

I'm sure you learned a lesson from what happened, I sure did!

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Specializes in tele stepdown unit.
Starcandy, I really don't see how this med error was your fault! You did what any reasonable nurse would have done. You did a lot of questioning and got the "correct answers" before you actually administered the insulin. Once you discovered what had happened, you filed the incident report.

Don't beat yourself up over this! Hopefully they will track down who originated the error.

When I told my supervisor, I was led to believe it was all my fault. It made me feel really incompetent. I really am having a horrible week. I still stay late after my shift on a regular basis. I have been a RN for a year and wish I had a "true" mentor to help with my organization. I am really frustrated at this point.

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Specializes in tele stepdown unit.
One error does not a bad nurse make. You caught the mistake and owned up to it. It is not fun when you have to write yourself up (been there, done that :o - my goof was very similar to yours). I wish I could say all nurses are perfect and don't make mistakes, but we all know no one is error-free.

I know you feel horrible about the situation (I sure did). Use it as a learning tool. You know where you made the error and I'd bet a shiney new silver dollar you won't make it again any time soon.

You were right to question something you thought wasn't correct. Continue to do that. Always remember to verify the 5 rights - especially when you don't think something is correct.

I hope this doesn't come across as harsh or disjointed sounding. I'm in the middle of a very long, very boring night :yawn:.

Keep your chin up. You'll make it!!

Thank you for the vote of confidence.

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Specializes in Nursing Education.
When I told my supervisor, I was led to believe it was all my fault. It made me feel really incompetent. I really am having a horrible week. I still stay late after my shift on a regular basis. I have been a RN for a year and wish I had a "true" mentor to help with my organization. I am really frustrated at this point.

Star - I am so sorry that you are going through this struggle. Being a first year nurse can be and often is very tough. But, in time, it will get better and you will have a better handle on things. Please remember these feelings so when new nurses come to your unit, you can be the support system (or at least part of it) for them.

In relationship to the med-error, it frustrates me to read that a new nurse is made to feel bad about an error. It frustrates me because people do not fail, rather the systems in place fail and these systems need to be reviewed and fixed to prevent others from making the same mistakes. I am reading the book "Internal Bleeding" by Robert M. Wachter, MD & Kaveh G. Shojania, MD. The book illustrates how bad medicine is in relationship to blame for errors rather than looking at systems designed to protect patients. It is a really interesting book and can be quite frieghtening when you read it .... but , it is sure true!

Continue on your path, be super aware, but please do not beat yourself up over this anymore. I read that the patient is fine and there was no adverse outcome ... so, relax.

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Specializes in Med-Surg.

starcandy don't feel bad I have made med errors so your not alone. It do feel bad I know when it happened to me all I could do is cry and I thought I was the worse nurse ever but now I can laugh about and know that you learn from every mistake that you make. It helps to be a better stronger nurse. Just know you did the right thing. :p

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First off let me say I am sorry that you feel somehow to blame on this. You did all you possibly could, and more than would be expected. We who have worked awhile have all done med errors. I have seen some little, and some big. You need to be carefull....but also forgiving. :o

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I feel really bad because I gave someone Lantus 100 u sq and through later detection it wasn't ordered. When I first saw the order listed on the MAR I questioned it. I looked in the chart for the order and did not see it. I called pharmacy and was subsequently sent a copy of original order with the patient label attached. I asked the pharmacist whose name I do not remember :uhoh3: (learning lesson) if this was a large dose. It was within the dosage range, but on the high end. I checked the dosage range myself within the pharmacy website. and the pharmacist was right . I am thinking that the original order was lost, which could happen . I administered the med and hours later during reconciliation of meds another nurse noticed the same order with the same handwriting on another patient . We compared the orders and it was the exact same handwriting and signatures. We beleive someone sent the order down to pharmacy with the wrong name label attached. :uhoh3: I fillled out a incident report and notified the dr. and supervisor which didn't go over well. I should have called the Dr. but when I did notify him after the incident he was also confused on which med the pt was on.

I feel bad because this means I am not a safe and effective nurse I will probably be written uo for this incident. :crying2: Also the reconciliation process the night before may have caught this error. There were other drugs on the order sheet the pt should have not recieved. When I left in the am the pt bs was in the 130's range.

Hey, we have all made mistakes. Anyone that says differently is a liar. Don't be so hard on yourself and move on. the worse thing that could have happened is you would have to give the pt d50. its not that bad, really. I think it makes you a good nurse b/c only a conscience nurse would own up to it and be so upset. if you weren't upset then you would be a bad nurse. ok.

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Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.

Give yourself a break. This does not mean you were are an unsafe nurse, do did quite a bit to cover yourself. You are not the one who sent down the order with the wrong label. Ultimately, as you are the one to give the med, you have that responsiblity. But hopefully you work for an institution that is going to look at the process and will realize it wasn't you're fault.

Stop the blame game and be gentle. I can tell that you are a good and safe nurse. Best wishes.

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Specializes in tele stepdown unit.

Thank you all, for your encouraging words. I feel a lot better now,but I was made to feel like I was the stupid and the one who lacked judgement. I learned from this experience to be more cautious.

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