Anyone who says she doesn't is lying

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    I made my first medication error as a student. I thought it would be my last, but real-world nursing was a wakeup call.

    Anyone who says she doesn't is lying

    Like most students, I thought the 5 Rights of Medication Administration were a little… bogus. I wasn’t a kid; surely I could be depended on to have common sense. Weren’t the 5 Rights almost insulting to nurses? I had been giving medicine to myself, family members, children at the summer camp where I worked, residents at the assisted living facility where I was an aide before nursing school, for years. I never gave Tylenol where I should have given Benadryl or accidentally gave a medicine one hour later instead of four hours later. Certainly I never gave medication to the wrong camper or resident. I relegated nurses who made medication errors to that unfortunate class that includes nurses with substance abuse problems… a category I would never visit.

    I made my first medication error (that I know of) in my second semester of clinical, on an oncology unit. My single patient, an elderly man with acute myelogenous leukemia, was ordered for IV Zosyn. I had checked this carefully, made a care plan, wrote down in detail when I was to give the medications. Halfway through the morning, the doctor came through and increased the dosage. I think I was dimly aware of this, had read the order. At the time for the medication, I went to the refrigerator, checked the right patient and right drug. I knew it was the right time and the right route. I told the nurse I was giving the medication now, and she nodded and gestured me away. My clinical instructor was on call if I needed him. I hung the medication for the sweet old man without incident.

    An hour later, the patient’s nurse came to me, holding a bag of zosyn. “Why didn’t you give this?” she asked. “I did!” I responded, alarmed and defensive. “Then why is it here?”

    We went to the bedside and found the zosyn I had hung. Right patient, right drug, right time, right route… wrong dose. The pharmacy tech had brought the new bag without removing the old one, which had already been prepared. When I picked up the bag from the refrigerator, I didn’t notice there were two for that patient, and I never rechecked the dose. I felt cold and hot and nauseated. How could I have done such a thing?

    The nurse berated me for not checking properly and began to fill out an error reporting form. I heard her telling the other nurses about it. “Oh, just a student not paying attention,” she said with an air of weary superiority.

    When she finished making the report, she came to me. “You know your clinical instructor needs to know about this,” she said. “I can tell him about it if you want.” I sensed an eagerness in her voice. “I’ll tell him about it myself,” I said, insulted.

    I was surprised at how calm my instructor was. I didn’t know him well, but from the nurse’s reaction, I expected a blowout; possibly a suspension. “Okay,” he said. “Do you know why that happened?” I explained that I hadn’t checked the dosage. “I don’t think you’ll make that mistake again,” he said. “There’s a form you have to fill out for the school, and I think you aren’t allowed to make more than two errors, but you’re going to be okay.” In his record of the incident, the instructor included the line: “To the student’s credit, she took ownership of the incident and reported it to me personally.”

    In my previous jobs I occasionally had to deliver discipline to employees, and I felt like I hadn’t been disciplined enough. I looked at the situation as if I were one of my junior camp counselors, and went to the theory professor with a plan: I wanted to explain to the first semester students what I had done so they would know it can happen. They listened to my experience with interest, although I knew they were all thinking “but I would never do that”. Maybe I prevented a few errors. I know I provided an example.

    Naturally, I thought this would be the last medication error I would ever make, and to my knowledge I didn’t make any more during nursing school. My first job was at a busy hospital with a high nurse/patient ratio; I usually had 7-10 patients during the day. It was months before I felt like I had time for anything more than running around dispensing medication. One of my friends from orientation made the first medication error in our group. She confessed it to the charge nurse, a woman I had already grown to admire enormously as someone who always knew the right thing to do. “Well, call it in to the reporting line,” she said straightforwardly. “We all make medication errors. Any nurse who says she doesn’t is lying.”

    My friend felt better, and I was startled. I had never heard this put so bluntly before. My instructors said it was easy to do, but they never quite got across to me that everyone does it. I filed this line away in my mind.

    I’ve made several medication errors since then. I mixed up a John and a Tom and the IV bags were found by the next nurse—the worst error that I’m aware of committing. (No harm to patients.) I’ve hung the right antibiotic at the wrong time. I’ve given whole pills where I should have given half. I’ve given medications that were discontinued a few minutes previously.

    Recently I gave a class on medication errors to a group of students, with examples. “These are all taken from my practice or were done by nurses I know,” I said casually. The students were shocked. “YOU did that?” one of them asked. “No, my friend did,” I said. Through my years as a nurse, with experience on various committees that look into incident reports, and many late-night confessionals among night nurses, I haven’t become immune to med errors--but I have come to understand them as part of nursing life. I’m quite sure I don’t make more errors than the average nurse; I hope I make less. I don’t usually make the same error twice (the exception being those half-pills—I was relieved when I moved to a hospital where all pills are split in the pharmacy). And I’ve counseled many students and new graduates through their first medication errors.

    And because I’ve learned that every medication error is a systems error: I report, report, report, and encourage others to do the same.
    Last edit by traumaRUs on Aug 13, '15
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  3. by   JustBeachyNurse
    Quote from BonnieSc
    Like most students, I thought the 5 Rights of Medication Administration were a little… bogus. I wasn’t a kid; surely I could be depended on to have common sense. Weren’t the 5 Rights almost insulting to nurses? I had been giving medicine to myself, family members, children at the summer camp where I worked, residents at the assisted living facility where I was an aide before nursing school, for years. I never gave Tylenol where I should have given Benadryl or accidentally gave a medicine one hour later instead of four hours later. Certainly I never gave medication to the wrong camper or resident. I relegated nurses who made medication errors to that unfortunate class that includes nurses with substance abuse problems… a category I would never visit.

    I made my first medication error (that I know of) in my second semester of clinical, on an oncology unit. My single patient, an elderly man with acute myelogenous leukemia, was ordered for IV Zosyn. I had checked this carefully, made a care plan, wrote down in detail when I was to give the medications. Halfway through the morning, the doctor came through and increased the dosage. I think I was dimly aware of this, had read the order. At the time for the medication, I went to the refrigerator, checked the right patient and right drug. I knew it was the right time and the right route. I told the nurse I was giving the medication now, and she nodded and gestured me away. My clinical instructor was on call if I needed him. I hung the medication for the sweet old man without incident.

    An hour later, the patient’s nurse came to me, holding a bag of zosyn. “Why didn’t you give this?” she asked. “I did!” I responded, alarmed and defensive. “Then why is it here?”

    We went to the bedside and found the zosyn I had hung. Right patient, right drug, right time, right route… wrong dose. The pharmacy tech had brought the new bag without removing the old one, which had already been prepared. When I picked up the bag from the refrigerator, I didn’t notice there were two for that patient, and I never rechecked the dose. I felt cold and hot and nauseated. How could I have done such a thing?

    The nurse berated me for not checking properly and began to fill out an error reporting form. I heard her telling the other nurses about it. “Oh, just a student not paying attention,” she said with an air of weary superiority.

    When she finished making the report, she came to me. “You know your clinical instructor needs to know about this,” she said. “I can tell him about it if you want.” I sensed an eagerness in her voice. “I’ll tell him about it myself,” I said, insulted.

    I was surprised at how calm my instructor was. I didn’t know him well, but from the nurse’s reaction, I expected a blowout; possibly a suspension. “Okay,” he said. “Do you know why that happened?” I explained that I hadn’t checked the dosage. “I don’t think you’ll make that mistake again,” he said. “There’s a form you have to fill out for the school, and I think you aren’t allowed to make more than two errors, but you’re going to be okay.” In his record of the incident, the instructor included the line: “To the student’s credit, she took ownership of the incident and reported it to me personally.”

    In my previous jobs I occasionally had to deliver discipline to employees, and I felt like I hadn’t been disciplined enough. I looked at the situation as if I were one of my junior camp counselors, and went to the theory professor with a plan: I wanted to explain to the first semester students what I had done so they would know it can happen. They listened to my experience with interest, although I knew they were all thinking “but I would never do that”. Maybe I prevented a few errors. I know I provided an example.

    Naturally, I thought this would be the last medication error I would ever make, and to my knowledge I didn’t make any more during nursing school. My first job was at a busy hospital with a high nurse/patient ratio; I usually had 7-10 patients during the day. It was months before I felt like I had time for anything more than running around dispensing medication. One of my friends from orientation made the first medication error in our group. She confessed it to the charge nurse, a woman I had already grown to admire enormously as someone who always knew the right thing to do. “Well, call it in to the reporting line,” she said straightforwardly. “We all make medication errors. Any nurse who says she doesn’t is lying.”

    My friend felt better, and I was startled. I had never heard this put so bluntly before. My instructors said it was easy to do, but they never quite got across to me that everyone does it. I filed this line away in my mind.

    I’ve made several medication errors since then. I mixed up a John and a Tom and the IV bags were found by the next nurse—the worst error that I’m aware of committing. (No harm to patients.) I’ve hung the right antibiotic at the wrong time. I’ve given whole pills where I should have given half. I’ve given medications that were discontinued a few minutes previously.

    Recently I gave a class on medication errors to a group of students, with examples. “These are all taken from my practice or were done by nurses I know,” I said casually. The students were shocked. “YOU did that?” one of them asked. “No, my friend did,” I said. Through my years as a nurse, with experience on various committees that look into incident reports, and many late-night confessionals among night nurses, I haven’t become immune to med errors--but I have come to understand them as part of nursing life. I’m quite sure I don’t make more errors than the average nurse; I hope I make less. I don’t usually make the same error twice (the exception being those half-pills—I was relieved when I moved to a hospital where all pills are split in the pharmacy). And I’ve counseled many students and new graduates through their first medication errors.

    And because I’ve learned that every medication error is a systems error: I report, report, report, and encourage others to do the same.
    Accepting responsibility for ones actions is the first step. I think the first step should be like your instructor to ascertain how/why it happened and how can we prevent it from happening again. I've not made a medication error but I have made an enteral feed error as the discharge paperwork was confusing and I did not clarify with the ordering physician like I should have. Worse the covering resident misread the discharge orders and gave a completely different clarification, one that would have resulted in double volume and rate (huge issue when using JTube feeds in a little pediatric patient with severe reflux and vomiting. Fortunately this was more obvious as I knew the maximum feeding rate for a child this size was around a third of what the resident was requesting) No harm but what a horrible feeling to make a mistake that could have been prevented if just one extra step...
  4. by   Farawyn
    It's true that medication errors that "do no harm" seem to be more forgivable than other infractions by TPTB. I've made a couple that I know of and still remember what it was and what I did wrong.
    The sinking feeling in your gut realizing that this was a preventable mistake is awful.
    I haven't made a med error in about 10 years and I'm trying to keep it that way.
  5. by   Jules A
    I once heard and happen to believe that nurses who have worked any length of time and assert they have never made a med error are either lying or too stupid to have figured out they made one. Neither is too comforting imo. They happen, some of the best nurses I know have disclosed doozies they made during their career. We can only strive to follow the safeguards in place, hope no one is injured if an error happens and learn from our mistakes.
  6. by   NurseGirl525
    I'm a student and I don't think the 6 Rights are bogus. I do it every single time I administer meds. I know that in the real world of nursing, things will be very different than my protected bubble of clinical, but I'm hoping that I will never make one. I'm too scared of killing someone.
  7. by   gibsongirl
    Medication errors are often more than one persons mistake. The pharmacy should have removed the bag with the incorrect dose. I know what you feel like. I just can't skip a right once or there will be a problem. My first med error was wrong route. My last error was wrong route. I can remember them like yesterday. 33 years apart. Once, I did the 5 rights and didn't notice the med expired the day before! I really hated reporting that one. I had one other that I recall, in those years somewhere. Thank God, no injury. Once, our pharmacy distributed Dilantin liquid with 10x the correct dosage! I'm glad med errors are handled differently now. More of an investigation of cause so it can be avoided. Less bad professional, more bad system.
  8. by   BonnieSc
    Personally I hate that some schools are now teaching "the six rights"--the sixth right being Right Documentation. Five is enough, five is for patient safety in administration. Yes, we have to document, but that isn't specific to medication safety. Five is easy to remember and has a good mnemonic in the five fingers. " Right Documentation " has just been a distraction to my students.
  9. by   sommer0515
    I think the 6th right was probably added bc of technology. I've scanned in meds and the system warn me of an "incorrect" dosage when it's a half pill, etc.. And you have to manually correct it. Also, it could be an extra safety precaution to document any info pertinent to the drugs itself (k levels for Lasix, HR for Dig..) or why clinical decision was made to not administer.
  10. by   Susie2310
    Yes, of course nurses make mistakes, but the OP seems to be downplaying nurses' medication mistakes. None of the OP is devoted to the serious effects of medication errors on the patient. While some mistakes can indeed be attributed to "systems errors", some mistakes are actually individual nurse errors. When I was in nursing school it was drilled into us to use the five rights three times for every medication we administered; we would never have thought of the five rights as bogus. If we had violated the five rights, as in the OP, by not checking the dose, which resulted in a medication error, I am pretty sure we would have been dropped from the program. Your instructor sounded very lenient. In our program, our clinical instructor was always present when we administered IV medications.

    It seems as though sloppy practice is just accepted nowadays, to the detriment of the patient. Really, it's not that hard to check five rights and properly understand the purpose of the medication, reason for giving, side effects, contraindications, assessment information necessary before giving, etc. Slow down and think about what you're doing. Yes, nurses make mistakes with medication administration, but the OP seems to be downplaying the great responsibility nurses have for administering medications safely and correctly, and the sometimes serious /sometimes less serious consequences for the patient of not doing so.
    Last edit by Susie2310 on Aug 13, '15
  11. by   Susie2310
    Duplicate post.
  12. by   CBlover
    I can't understand a clinical instructor like you had in school who would not go with you to give a medication!! You said your clinical instructor was on call?? What does that mean? You weren't an RN yet. It was his/her fault!! When I was a student and the same goes for students that come for clinicals on the unit I work in, the instructor stays right by their side when giving meds and watches every move like a hawk.
  13. by   BonnieSc
    I'm not going to argue with how my post was perceived, but I will say that I was taking a particular angle for this audience of nurses, which wasn't to say how bad medication errors are; it was to say that they're common. The more open we are about medication errors, the more likely they are to be prevented. My purpose is to advocate for more openness.

    Re: the clinical instructor--practices are different for different schools/hospitals. My memory on this point is a bit vague, but I do think there was a point where the nurse I was working with was supposed to come with me or doublecheck the medication and didn't. Even if that was so, as far as I'm concerned the fault was mine, not hers--her responsibility was on her own conscience. I had been taught the proper procedure and didn't follow it. In that clinical placement, my group of ten people was spread throughout three units in the hospital, and there was no expectation (then or at any clinical placement I can remember) that the instructor checked our meds or was with us when we gave them. I have experienced that with students from other schools as a nurse, though.

    As for whether a student who makes a medication error should be suspended, I think absolutely not (barring extenuating circumstances; assuming it's a standard sort of error), any more than a nurse should be fired for making one. Medication errors are [supposed to be] reported anonymously for a reason--because they are system errors, or could possibly be prevented by a change in systems. Punitive reactions to medication errors only make nurses go into hiding when they make one.
  14. by   Susie2310
    Quote from BonnieSc

    As for whether a student who makes a medication error should be suspended, I think absolutely not (barring extenuating circumstances; assuming it's a standard sort of error), any more than a nurse should be fired for making one. Medication errors are [supposed to be] reported anonymously for a reason--because they are system errors, or could possibly be prevented by a change in systems. Punitive reactions to medication errors only make nurses go into hiding when they make one.
    The point of dismissing students from the program I attended for medication errors was partly to impress upon students that medication administration using the five rights was to be taken seriously, and was not to be regarded as "bogus."

    You appear to want to absolve the nurse of individual accountability for medication errors. Medication errors "may" be due to "systems" problems, but are often due to individual nurse errors. Failure to use the five rights to administer medications safely is often not a "systems" problem, but an individual nurse failure. For instance, failing to properly identify the patient at the bedside; failing to confirm patient allergies; failing to verify that the dose of the medication is the same as the physician ordered and is appropriate for the patient to receive at the time of administration based on the patient's current medical condition; administering the medication by the wrong route when the physician has clearly stated the route; miscalculating the dose of an IV push medication and administering the wrong dose; failing to administer a dose of a medication at the ordered time because one doesn't read the MAR correctly, are all individual nurse errors. Of course nurses should report medication errors; but we can be big enough to not blame all our mistakes on "systems" problems.
    Last edit by Susie2310 on Aug 13, '15

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