My first med error

Nurses Safety

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I've been a grad nurse for about 2 and 1/2 months now and I made my first med error without realizing it. It was brought to my attention the next day by the night nurse who caught my error. The order was for IVP dilaudid that has 3 different doses dependent on pain scale. For a pain level of 8-10 the dose was 1.2 mg but I only saw the 2. So I gave this pt 2mg of dilaudid by mistake a few times that shift. Luckily she was perfectly fine, with no adverse events. However I'm not fine. I replay it in my head over and over trying to understand how I could have made that mistake. I can't sleep and all I can think about is everything I've probably screwed up. Needless to say my confidence is shot. I'm now wondering if I can't handle the med/surg floor I work on or if I'm just not meant to be a nurse. This is a very difficult error to face, it's embarrassing and exhausting. Please if anyone has any input I'd appreciate it.

There are many threads about this very topic. Read those and I bet it'll help a bit.

Just remember--everyone (nurses included) makes mistakes! If a nurse says s/he hasn't--either it's a lie or s/he is too stupid to know.

Use it as a learning experience---I'd be willing to bet that from now on, you always pay closer attention to reading orders, especially range orders.

Learn from it, put it behind you, and go on. You're gonna be okay!

Specializes in Med-Surg., Oncology, Observational Units.

I agree with MessyMomma. Instead of letting this situation get the best of you turn it into a learning opportunity. It is true all nurses make mistakes but a large percentage may not get caught or brought to your attention. I made the mistake a couple of years ago by rushing a SC insulin injection in a Hep C positive pt and stuck myself on accident. Fortunately, all my test were negative after six months. Anyways, that situation really worried me but I learned to be more careful and take my time when giving patients injections. To this day, when I precept new nurses I make sure they take their time when giving injections and retract the needle with one hand.

I have found great nurses usually make mistakes because they are in a hurry or they are afraid to ask a question. So take your time on the critical task and ask questions if something is not clear. Good luck, you will be fine.

Specializes in Pedi.

Does your facility not have a policy for double checking narcotics?

Specializes in med-surg, home health, dialysis, NICU-MB.

While it's never good to make a med error...it happens to the best of us ---even the most seasoned nurses! Fortunately the patient was not harmed and you can look at this as 'an opportunity for improvement'. I know that after this experience you'll be much more careful about checking med orders.

The fact that this bothered you so much means that you really care and that you want to do the best job possible. It's ok to put this behind you and to go forward all the wiser. Just be more aware and you'll do fine!

Specializes in Acute Rehab, Progressive Care.

I am a new nurse too. I am 6 weeks into my orientation and I have already made 2 med errors - both were missed scheduled doses - so I feel your pain. I was "doing well" so my preceptor & bosses pushed me from 4 patients to 5, then 6. Then, I ended up having 2 days almost completely on my own, due to people not showing up for work, going home sick, etc. People stopped supervising me and weren't around to answer questions or I had to wait to get my questions answered. Sometimes my judgment wasn't good, I realize now - I would just get overwhelmed and "fly by the seat of my pants" trying to get everything done.

Now they have put me back to 4 patients and on careful watch because of my errors. I am afraid I'll get fired if I make another one, so I have made a couple of resolutions/changes to try to help me not make another mistake. First, I have a new "brain sheet" I devised with common medication times listed. When I come in in the morning, I circle the times the patient has meds to be given, and I check them off in red when that med pass is completed 100% for that patient. So if patient Joe has meds at 0800, 0900 and 1400, I circle those times next to Joe's name, and after I give him his 0800 meds, a red check. Also, I have to accept that the paper MARs at my facility are very confusing to me. Maybe other people don't find them confusing, or they are so used to them they no longer have any issues reading them...but I find them hard to read. Therefore, I no longer will let another nurse pull meds for me. Sometimes they want to to try to be helpful, but I need to look at the MAR the extra time to be 100% sure I have seen every order all 3 times (3 checks). There are still times when I have to go through the book an extra time or two to find every order. I have to let myself take the time, I realize. I am still new and learning and if my med passes take longer then they take longer. Better to take longer than to miss a medication, give the wrong medication or the wrong dose. I have a list in my clipboard now of "time critical" meds, and every morning when I get to work I pull it out and look at all my MARs to see if any patients have those "time critical" meds and flag those pages with red post it notes - at my facility that would primarily be antibiotics and oral diabetes meds. Then I note it on my brain sheet too. I also note "high alert" medications like insulin, heparin and others. When I have odd dose amounts of narcotics and have to waste, I get someone to witness me up front, so I don't forget to do it later.

Sit down and think of ways you can help yourself remember. We can't be perfect, but we want to try to address the problems and give ourselves the best chance of success in a very stressful environment! Prayers and hugs to you...

Thanks for sharing the ways you tried to prevent future errors for yourself. I too was pushed up to 5-6 pts when I felt I wasn't ready..this job is so overwhelming. But I've come to the same conclusion as you, I can only give mess safely at my own pace and if its slower than everyone else so be it, at least it's safe. Good luck to you, hopefully this time next year we will both be much more comfortable in our nursing roles!

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