Has anyone made a medication error and *not* get fired for it?

Nurses Medications

Updated:   Published

I screwed up tonight, plain and simple. I had meds pulled for two patients and started giving meds to one patient. I pulled the pills in their packages out of the cup and told him each med and their dosage. The second after he put the cup to his lips, an "oh ****" comes out from under my breath. I realized that what I had given him was intended for the other patient and that I had made an error. I walked back to the nursing station, told another nurse, told the charge nurse, called the doc, got an order for Benadryl to prevent any undue reactions, however unlikely, filled out an occurrence report, documented in the chart (without saying it was an error) and made it through the rest of my shift. Everyone was telling me that it was okay and I did the right thing, but I'm terrified. I'm thinking about calling my supervisor in the morning and admitting my screw-up before she gets the wrong idea. Is this nuts?

itsnowornever said:

When we were short Nubian we had 10mg stocked instead of our usual 20. Pharmacy filled our stock back with 20 and didn't mark ANYTHING or tell ANYONE. I Caught the error on count and spent the next 30 min highlighting the back and front labels of all the 20mg so no one would make a mistake- who knows which patients received 40 instead of 20...that was a dangerous mistake waiting to happen.

?

What error did you catch?

No nurse should be giving anything without reading the label regardless of what is usually stocked.

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Specializes in Critical Care.

yup. i was orientation. my preceptor saw it and calmly notified me i had hung 20meq of K vs the correct 10meq. i was horrified, ran to stop it, asked which dr i should call, who i should i report myself to, etc etc

he said, "well run only 1/2 the bag at less than half the speed and dont take your eye off of him. his K was so low that he should have been ordered 20meq IMO.'

UMMM YEAH never clicked on the wrong K bag in the pyxis ever again.

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There has been a lot of articles about medication errors. The Institute for Safe Medical Practice is a great resource. There has been a lot of emphasis placed on having hospitals follow what the FAA does.

When an airplane crashes unfortunately the pilot usually dies and can't be fired. But the FAA does not just write off every airplane crash as "pilot error." They go over every inch of evidence with a fine tooth comb to find out why the airplane crashed. The emphasis is not on who to blame. The emphasis is on what caused the crash. Their next step is what do we do so this doesn't happen again. No matter if a person, mechanic, pilot, etc., was found to be at fault they don't automatically get fired. Their actions are gone over to see why they made the mistake and how to prevent others from making the same mistake.

Hospitals should be, some are, doing the same thing. What caused a nurse to give the wrong medicine. The factors vary from look alike, sound alike, drugs, to too many interruptions when a nurse is getting medications ready, to simply re-educating that nurse, etc.

Sure some nurses just don't get it and need to be fired. But a good nurse should never be fired. There are always extenuating circumstances when things go wrong.

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BrandonLPN said:
Any nurse who says she's never made a med error is either lying or dangerously unobservant of her own practice.

Few things are worth repeating but this is one.

I made a big error in the first couple months of my first nursing job. Pt being discharged, we sent 3 days of meds home in ziploc bags for every pt. we were short on bags so ADON told me to double up meds in one bag and mark which two meds were on there. I wrote all dosages correctly on discharge papers but when I wrote them on the ziploc bags I accidentally doubled the dose of Lasix. Pt went off the bag and not the discharge paper. He ended up being fine after going to ER as a precaution but I cried for days! My boss put me on 30 day probation and I had to prove how I was going to stay organized. I had 30 long term care and rehab patients the day I discharged that patient, I was just really overwhelmed with wounds, g tubes, etc. not an excuse though and I am super careful now , triple check every tiny thing I give.

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Specializes in LTC.

So whatever happened???

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OP: Yeah, that would pretty much be ... all of us. Go forth, make a good act of contrition (oh, right, you did that ? ) and sin no more. Have a good night's sleep, fergawdsakes. ?

1 Votes
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
dolcebellaluna said:
I screwed up tonight, plain and simple. I had meds pulled for two patients and started giving meds to one patient. I pulled the pills in their packages out of the cup and told him each med and their dosage. The second after he put the cup to his lips, an "oh ****" comes out from under my breath. I realized that what I had given him was intended for the other patient and that I had made an error. I walked back to the nursing station, told another nurse, told the charge nurse, called the doc, got an order for Benadryl to prevent any undue reactions, however unlikely, filled out an occurance report, documented in the chart (without saying it was an error) and made it through the rest of my shift. Everyone was telling me that it was okay and I did the right thing, but I'm terrified. I'm thinking about calling my supervisor in the morning and admitting my screw-up before she gets the wrong idea. Is this nuts?

*** Ya, kinda nuts. Relax. You made a mistake and immediately owned up to it. I have never heard of any nurse getting fired for a medication error unless there was a lot of lying to cover it up.

1 Votes
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
HippyDippyLPN said:
I made a big error in the first couple months of my first nursing job. Pt being discharged, we sent 3 days of meds home in ziploc bags for every pt. we were short on bags so ADON told me to double up meds in one bag and mark which two meds were on there. I wrote all dosages correctly on discharge papers but when I wrote them on the ziploc bags I accidentally doubled the dose of Lasix. Pt went off the bag and not the discharge paper. He ended up being fine after going to ER as a precaution but I cried for days! My boss put me on 30 day probation and I had to prove how I was going to stay organized. I had 30 long term care and rehab patients the day I discharged that patient, I was just really overwhelmed with wounds, g tubes, etc. not an excuse though and I am super careful now , triple check every tiny thing I give.

*** Wow, 30 days probation? Harsh for such a simple mistake. How did the manager punish herself for her bad suggestion to you and her failure to properly supervise the person who was supposed to get ziploc bags?

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Specializes in Orthopedic, LTC, STR, Med-Surg, Tele.

No... I have made a med error, reported it and everything, didn't get fired. Even one of the clinical leaders on my floor made a med error. It happens - there's a difference between a simple mistake and gross negligence, however.

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She didn't punish herself...you know how long term care goes, blame the person below you. It taught me a very valuable lesson though, always always cover your own ass :)

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Specializes in Acute Mental Health.

I gave a pt haldol IM and even though something was 'nagging' at me, I didn't listen and as soon as I gave the med I too said Oh **** under my breath because I finally realized that the 'nagging' feeling was me not checking his allergies. Sure enough, it was listed. We paper chart everything so I had to give Benedryl and watched him very closely. All was well, but nope, I didn't get fired. I sure haven't made that mistake since. Owning up and admitting to everyone was tough, but my pt comes first, always.

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