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

[pinkiepieRN]

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?

[gigglestarsRN]

Quote

I almost made one last night.

The patient's wife was telling me I was such a great nurse. Ironic, because while she was doing this, I was about to hang an incorrect IVPB. Luckily, I always look at the label closely one last time before programming the pump and caught the error before I hit, "start."

On a side note, it's funny how patients/their family members define a, "great nurse." Interpersonal skills/customer service skills are all they seem to consider when making this determination. I had gotten her pillows, blankets, fresh ice water, etc. right before I almost hung the wrong IVPB. Even after the incident, they sung my praises. Probably, because they were too distracted by my excellent customer service skills (gag me) to notice my nursing skills were actually sub-par.

Don't be so hard on yourself, you did catch your error before it actually was one, kudos to you and double and triple checks!! I thought I made an error the other day when I gave insulin based on a verbal sugar. After I had it checked and gave it I logged on to our computer charting to get their sugar trends and my heart sank when I saw a different value. I panicked. I then noticed the time, it was the morning sugar in there and the afternoon had just been taken and the glucometer not yet docked to download results, hence taking a verbal. It turned out to be correct but served as a good reminder why we should not take verbals, lest you be given the wrong value. Good reminder without having an actual error bc that feeling stunk!!

[baptistbsn]

Vespertinas said:

My advice... you know you made a mistake and you did everything right to fix it. Keep this between you and the only people who have to know about it. You filled out an occurrence form and that will get back to your supervisor. He/she may process it and move on or may want to speak to you. Leave that alone, too.

Absolutely. Tell only those that need to know. Let it go.

We had a nurse allegedly give a med to a pt and it "didn't scan." Well duh, it wasn't ordered and wasn't in the computer! I'm sure she took it for her own use. She put the opened wrapper BACK in the accudose! I was sure she was history... nope... still works there, but did transfer.

[DoGoodThenGo]

Not to beat this dead horse more but just to put things in perspective:

Should nurses be fired for fatal medication errors?

[TheMediaLies]

I made some here and there. And yeah, you feel like a complete moron afterwards , but you suck it up (learn from it) and keep on working. Slowing your row down helps.

[cardiacqueen]

I've been a nurse for a year and I have made 2 med errors; reported both. No harm came to the patient either time...and I will never make either of those errors again...I was lucky, and honest. I did not lose my job.

[THELIVINGWORST, ASN, RN]

Seems like computer charting would help avoid a lot of these problems.

[firstinfamily, RN]

It looks like you have your answer. Never pull up meds for more than one patient, and as long as you reported your mistake, filled out the incident report etc. you have done all that is necessary. The supervisor will most likely get the notice, so you do not need to call him/her. Learn from your mistake and move on. We all make them, all of us are human and things happen. The learning process is knowing that you made it and how and to not let it happen again. Sometimes processes are changed because of the mistakes we make and practice is improved

[caliotter3]

When I have worked in LTC facilities, many times med errors were discussed, but in terms of "not going to say anything". The one exception was the nurse who used to "create" med errors for her coworkers so she could get them in trouble. Everyone else might talk about it at the nurses station or in the hallways, but they never took the matter up with supervisors. So, no one was ever fired, except for the backstabbing nurse who brought herself down.

[AnnieOaklyRN, BSN, RN, EMT-P]

yup, gave a patient 2 mg IVP of Dilauded instead of 1 mg IVP. Thankfully no ill effects, she was high as a kite and liked it and 20 minutes later was asking for more!

Errors happen, you just have to learn from it, and move on.

HPRN

[sistrmoon, BSN, RN]

SlinkyheadRN said:

Seems like computer charting would help avoid a lot of these problems.

Uhhh, not necessarily. I made an error that was essentially a systems failure with our med administration system.

[PMFB-RN, RN]

SlinkyheadRN said:

Seems like computer charting would help avoid a lot of these problems.

My experience is that the oppisit happens. Computer charting takes so much longer, and is so much more work, and requires so much more concentration than our old tri-folds that the nurse has much less time with her patient and less time to concentrate on the med pass.

I used to be able to do 12 hours worth of charting on two very sick SICU patients in 15 min with the old paper charting. Now it takes hours and hours each shift just to document. No just for old guys like me either. The younger nurses are also taking hours each shift to chart.

[THELIVINGWORST, ASN, RN]

Perhaps it's your system that you use. Takes me no more than an hour to chart everything if I'm being slow.