Made a PainMed Charting Error- help?

[newnurse2014]

I am a new graduate nurse and I'm in my first job. Yesterday my preceptor let me take the reigns and do the majority of the work. I'm in the 6th week of orientation, with 6 weeks to go. I just realized that this happened and have already contacted my preceptor about what to do. I'm looking for advice on what to expect to happen to me... written up or fired or what?

We had a patient who was receiving dilaudid. We took care of her the previous day and knew that she takes 1mg IV, but the order is for 2 mg IV. When we got it out of the Pyxis system we had to witness a waste of the extra 1 mg. Each time she received the medication, this was done, so it is in the Pyxis system that we wasted and only 1 mg was given... however, when I scanned the medication in I totally spaced and didn't change it to 1 mg in the computer system. So it was documented that she received 2 mg IV dilaudid every instance on my shift yesterday even though she didn't.

Of course, we'll be letting my manager know and I'll take whatever punishment I deserve, I'm really worried about this and freaking out about it. I'm already beating myself up about it. So please, no negative comments because I totally understand my mistake and it will never be made again.

[ricardoj]

Mistakes happen. I wouldn't lose sleep over it.

[Here.I.Stand, BSN, RN]

I highly doubt you'll get punished over it. There should be a way in your system to edit your documentation; how I would do it on mine is go back to the 2 mg entry, click "edit administration," change the 2 mg dose to the 1 mg that the pt actually received, and enter a comment on why I was editing.

It's like on paper charting, crossing something out and writing "error" with your initials.

Just an FYI, something you may want to bring up w/ your IT people: in the system we use, when you scan a med if the dose is different than the ordered dose, you get a big red warning pop-up. "Dose scanned is more than ordered." Then you have to enter a reason why--in this case you click "partial package." A feature like this would 1) prevent you from inadvertently charting the entire vial, and 2) work as a safety feature so that the pt DOESN'T get a full vial if not ordered.

[toomuchbaloney]

Do I understand that you were giving half of the ordered dose because that was effective?

Due to an error in your interaction with the technology it appears that you administered the ordered rather dose rather than the smaller dose?

If those things are true you have done nothing wrong but have simply made a 'clerical' error which can be remedied.

[sapphire18]

Although this could be considered a med error since the ordered dose was 2mg and you were only giving one- you should've asked for the order to be changed.

[klone, MSN, RN]

And that's why it's so important that wastes are witnessed!

Can I ask, if the order was for 2mg, why were you only giving 1? Unless the order was written as a range, that would be a med error. If you felt that the patient only needed 1mg, the appropriate course of action would be to contact the physician to amend the order to provide a range, so that you can use your judgment as to how much to give the patient.

[toomuchbaloney]

Right that about ranges. I am so accustomed to working in that sort of environment where I, as the administering professional, is expected to use critical thinking relative to administration of pain medications that I forget that it is not ALWAYS like that.

Thanks for the reminder.