med error

  1. I work in a state psychiatric hospital,. 3rd shift, where I made a very serious med error. The patient involved is non-verbal with no wristband or identification. We are to have an aide as patient identifier on the med line but we are always short staffed so we never do. There were two RN's on that morning but one had been asleep in the break room since 2AM and the other was in the day room with the patients.

    As I said, I confused two patients. Their photos are very similar and they look very much alike. I gave the full slate of psych meds to the wrong patient plus 40 units Novolin N- he was a non diabetic.

    Twenty minutes after this happened, I was looking through the MAR when I realized my mistake. I checked the two clients, was assured of my error and reported it to the charge nurse. The nurse who was in the day room felt we should cover the error, an option I had already discarded when I reported the error to her. I have seen other nurses do that and it seems to sour their practice long after the incident.

    Anyway, the nurse who had been sleeping for most the shift came and she filled out the med error report' I was in tears. The doctors came and the patient was fine- he had hourly blood sugars and vital signs with no reading out of norml for 24 hours. For a week, I heard nothing. Then i got the news that I was being removed from the med room and would be working as an aide until further notice. This has been going on for two weeks. Though I feel I'm being tortured I don't dispute that I made the error and I should have some consequence, though this seems extreme.

    At that time the head of nursing said that I would need to get more training and that would be the end of the incident, but two days later, she resigned(under pressure). Her #2 told the union that I should be subject to 10 days suspension in addition to the training.

    I can't tell you how upset I am. I am at work every night and am humiliated to have to be working as an aide- though I am being paid my full salary. I have been told that it would be a mistake to leave while this is going on.

    I have been an LPN for one year. I am currently doing my last two courses to qualify to enter an LPN to RN program. I feel I've thrown everything away.

    EVERYONE at this job thinks it will make me feel better if they tell me about similar errors they have made and covered up. Some have sent clients to the hospital. I am horrified. I do not want to be that type of nurse but clearly the treatment I am getting demonstrates that there is no encouragement for reporting med errors. What am I doing in this place?

    I've stayed at this job because it is 5 minutes from home, has excellent benefits and pays for my education 100%. I was in line for a full scholarship at full salary for my RN program but obviously that is out the window.

    Any words of wisdom?
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    About learning lpn

    Joined: Sep '08; Posts: 2; Likes: 2


  3. by   nightmare
    Why was the RN sleeping in the break room?!
  4. by   learning lpn
    Welcome to the world of state psychiatric hospitals.
  5. by   nightmare
    I've worked 17 years on nights,plus a few before that in RICU never had time to sleep,didn't get paid to sleep!!
  6. by   ohmeowzer RN
    you made a error we all do.. you are only human , the man was okay .. you were honest about your mistake and you need to be commended for that...

    how can they make a LPN and aid? people make med errors all the time and are not made aids.... that is the craziest thing i have ever heard,,

    that RN should have been turned in for sleeping on the job...

    i wish you well, it will all work out for the best,,, keep us posted
  7. by   nightmare
    If we make med errors then there is a period of 'retraining' In other words someone oversees your med round to make sure you are doing it properly.After this you are back on track but never demoted to aide/carer.
  8. by   racing-mom4
    Ya it sucks, no question about it, you did the right thing by admitting your mistake and hopefully some policies will be better enforced 1) being no sleeping in the break room---my lord...even though devils advocate though, you let her get away with it so it is just as much your fault as hers...2) a 2nd lic personal for id verification needs to be present for admin meds to non verbal patients with out a ID.

    I dont know why your tuition would be out the window though--they are not firing you, so the contract should stay the same that they will pay your tuition.

    Just suck it up and dont let it get you down, easy for me to say sitting here at my computer I know, but like you said good benefits, job close to home and tuition. You will get through this, focus on school and next semester this will be a thing of the past...

    And dont let anyone get away with sleeping any more!!!
  9. by   Mulan
    I really don't understand why nursing homes, psych hospitals, whatever can't have the patients wear some kind of an ID. That is just setting people up to make an error, in my opinion.

    Just use it as a learning experience, what you would and wouldn't do, and concentate on the benefits to you to continue to work there.

    I feel for you.

    Good luck.
  10. by   romantic
    "Just suck it up and dont let it get you down, easy for me to say sitting here at my computer I know, but like you said good benefits, job close to home and tuition. You will get through this, focus on school and next semester this will be a thing of the past..."


    I admire and respect you for your integrity. During my clinical rotations, as a nursing student, I saw some (not all!) nurses covered their mistakes. In my opinion, you did the right thing admitting your med error. You should be proud of yourself -- one has to have the guts to do what you did, knowing what will follow after... when my turn will come, I want to be as honest and brave as you are. It's better to live with clean consciousness.
    About your punishment... They don't fire you or suspend your license... I agree with you that it's humiliating to work as an aide, but look at this as a temporary state -- it'll go away. The most difficult and important thing you did right! Concentrate on that, not on your punishment.

    We all are humans and we all make mistakes. The most important thing what we do after; do we cover our asses or stand up and take responsibility for our actions. You did the right thing!

    Please keep us posted.
  11. by   iwanna
    Do not let this get you down. I am sure that you are not the first to make a med error where you work. I don't feel that you should be punished for the med error, however, the biggie was the RN sleeping. It sounds like you took the total blame for this scenario. Kudos to you for being honest and looking out for your patient. You did the right thing. I am sure that you have learned to wake up the RN.(who should not be sleeping on the job in the first place) We sacrifice our licenses at times by being too nice. I know that I had an incident once that should have been reported. The RN pleaded with me not to report that a patient fell, as she already had another accident report the day before. Also, I was the only nurse on the unit. Actually, I was the only employee on the unit. But, as a result of that incident, I had many sleepless nights over it. I felt tremendous guilt for not reporting it. I was jeopardizing my license for the unit RN. It was not worth it.
    You will get through this. Hold your head up high, as you did the right thing. I don't see how this would jeopardize your tuition for bridge program.
  12. by   Jules A
    I just wanted to echo what everyone else already covered. I totally feel for you as this seems very unfair. You did the correct thing so don't doubt yourself. If possible hang in there and just remember the close proximity to your home and good benefits. Hugs, Jules
  13. by   justme79
    I guess it is no surprise that so many nurses where you work cover up their mistakes instead of creating an environment of learning and patient safety!
  14. by   PICNICRN
    First let me say that I am so sorry about your situation, no one sets out to make a mistake.... unfortunately, we are human and the mistakes do happen.
    My questions/concerns to you are....

    Why was this RN sleeping?? Is the RN supposed to be "in charge" of your unit?

    Why did the pt not have an ID band?(I know nothing about psych-is this common?)

    Do you not need a second nurse to check your insulin doses? This is required now in many hospitals.

    As usual when med errors are made-- you seem to have been set up for failure. Perhaps your employer should spend more time looking into improving their policy and less effort in punishing you!

    Hang in there and think of this as a learning experience

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