Med error

  1. So... I made my first med error today... a big one. I am new to nursing, been a nurse for a little under 10 months. I was asked to come in and cover 4 hours today for a sick co-worker. I walked in to a patient in the ED complaining of chest pain. My coworkers had started the ER and I jumped in to help right away; I took over the ER after getting report for my other nurses and waited for further orders from my provider. Long story short, I was ordered to hang a heparin infusion (which I have done before) and give an initial bolus of 4000 units... I calculated the concentration which came out to be 25,000 units/ 250 ml D5W. I called my provider to check the rate to be hung and was ordered to give 12 units/ kg which in the this patient would be 1146 units. I did the math while on the phone and double checked with the provider. I got up, walked into the ER and hung that bag.... at 1146.....1146 mls..not units. I poured that bag of heparin into my patient...

    I realized my mistake shortly after when I was looking the MAR to prepare my report for the receiving facility.... My stomach just dropped... As soon as I saw the ordered rate I just about puked... I can't believe I did that...

    I picked up the phone, called my provider and owned up to what I had done...Trying everything in my power to not burst into tears on the phone. Mean while, I am looking at my patient, scanning for any signs of my mistake. Vitals are good, BP still elevated, but not any higher than initially.

    My provider handled it better than I would have if I were him. He called the cardiologist for orders - I was told to just monitor for signs of bleeding. The patient remained completely stable while in the ER and was transferred without problem. I followed up with my provider after the incident and discussed my areas of improvement.

    The thing that upsets me the most is that I have literally no excuses! I was not tired, or side-tracked. I was not any busier than any other day, in fact it was a pretty mild ER considering. I had staff members available to help me, and I had even double checked my order with the provider! This was not a new task, I had mixed and calculated heparin drips before. I was not overwhelmed or having a bad day... I just simply made a mistake...

    I have been crying for hours now... I know the patient is ok, and I am thankful. But Lord, I do not want this one mistake to ruin my career. Any advice from some seasoned nurses?
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  2. 18 Comments

  3. by   Ben_Dover
    Where was your second verifier prior to starting your heparin and/or are you in the U.S?
  4. by   hppygr8ful
    Ok, so first things first. Yes you made a mistake (A big one) but the good news is no harm came to the patient so wipe your eyes, take a deep breath, learn from this and carry on. If you ever meet a nurse who claims to have never made a medication error know that they are lying. It happens to all of us. Accept whatever consequences result from this and again I say move on. Most medication errors happen due to a systems breakdown and not because of any deficiency on the part of the nurse who made the mistake.

    You will get through this and be a better nurse for it.

    Hppy
  5. by   NurseD0816
    Yes, in the US. The order was not in the computer yet, so that is the first place it went wrong. The nurses do it all the time at my facility and I started to do the same... Also, meds can't be barcode scanned in the ER because the aren't verified by pharmacy yet. So, I hung the med, with the incorrect rate and checked it off the MAR after it had been infused. All bad. I will be meeting with my DON to discuss all of this, and hopefully make changes for the better.
  6. by   Nurse Beth
    Quote from NurseD0816
    So... I made my first med error today... a big one. I am new to nursing, been a nurse for a little under 10 months. I was asked to come in and cover 4 hours today for a sick co-worker. I walked in to a patient in the ED complaining of chest pain. My coworkers had started the ER and I jumped in to help right away; I took over the ER after getting report for my other nurses and waited for further orders from my provider. Long story short, I was ordered to hang a heparin infusion (which I have done before) and give an initial bolus of 4000 units... I calculated the concentration which came out to be 25,000 units/ 250 ml D5W. I called my provider to check the rate to be hung and was ordered to give 12 units/ kg which in the this patient would be 1146 units. I did the math while on the phone and double checked with the provider. I got up, walked into the ER and hung that bag.... at 1146.....1146 mls..not units. I poured that bag of heparin into my patient...

    I realized my mistake shortly after when I was looking the MAR to prepare my report for the receiving facility.... My stomach just dropped... As soon as I saw the ordered rate I just about puked... I can't believe I did that...

    I picked up the phone, called my provider and owned up to what I had done...Trying everything in my power to not burst into tears on the phone. Mean while, I am looking at my patient, scanning for any signs of my mistake. Vitals are good, BP still elevated, but not any higher than initially.

    My provider handled it better than I would have if I were him. He called the cardiologist for orders - I was told to just monitor for signs of bleeding. The patient remained completely stable while in the ER and was transferred without problem. I followed up with my provider after the incident and discussed my areas of improvement.

    The thing that upsets me the most is that I have literally no excuses! I was not tired, or side-tracked. I was not any busier than any other day, in fact it was a pretty mild ER considering. I had staff members available to help me, and I had even double checked my order with the provider! This was not a new task, I had mixed and calculated heparin drips before. I was not overwhelmed or having a bad day... I just simply made a mistake...

    I have been crying for hours now... I know the patient is ok, and I am thankful. But Lord, I do not want this one mistake to ruin my career. Any advice from some seasoned nurses?
    I'm so sorry for your experience, and so glad the patient is fine. Heparin has a short half-life and is reversible.

    This is all the more reason for smart infusion pumps that help prevent such errors.

    When you meet with the DON, tell her what you learned and what steps you plan to take to prevent future med errors.

    Then you have to forgive yourself and move forward. Best wishes
  7. by   Ben_Dover
    Quote from hppygr8ful
    Ok, so first things first. Yes you made a mistake (A big one) but the good news is no harm came to the patient so wipe your eyes, take a deep breath, learn from this and carry on. If you ever meet a nurse who claims to have never made a medication error know that they are lying. It happens to all of us. Accept whatever consequences result from this and again I say move on. Most medication errors happen due to a systems breakdown and not because of any deficiency on the part of the nurse who made the mistake.

    You will get through this and be a better nurse for it.

    Hppy
    Quote from NurseD0816
    Yes, in the US. The order 1. was not in the computer yet, so that is the first place it went wrong. The 2. nurses do it all the time at my facility and 3. I started to do the same... Also, meds can't be barcode scanned in the ER because the 4. aren't verified by pharmacy yet. So, I hung the med, with the 5. incorrect rate and checked it off the MAR after it had been infused. All bad. I will be meeting with my DON to discuss all of this, and hopefully make changes for the better.
    Hppygr8ful
    The OP DID Screw-up, with a BANG.
    But there are some errors that could have been "EASILY" prevented. The OP, as he or she writes, knew their was a system in place yet did not follow. So it's crystal clear that this error was not based on "systems breaking down." It's the USERS Fault.

    It seems like you learned your lesson. But please always practice common sense and I'm saying that in a most friendly way tone of voice.

    By the way, while meeting with your DON, you may want to discuss your salary increase, like you are the BOSS
  8. by   NurseD0816
    Thank you for the advice all. I spoke with my DON today and things changing for the better. Thank you again.
  9. by   Irish_Mist
    At my hospital, there has to be a second nurse present to verify a heparin drip. Even if that isn't your policy, ask another colleague to verify with you. If you are ever unsure of a med dosage calculation, ask another nurse to look at it.

    Yes, you made a rather huge med error. YOU ARE HUMAN. Mistakes are going to happen. Fortunately, the patient is okay and there is an antidote to heparin. Bet you won't make this mistake again. Follow your rights of medication, ask a colleague to verify if ever unsure, and you should be good to go.
  10. by   chare
    Quote from NurseD0816
    Thank you for the advice all. I spoke with my DON today and thingjs changing for the better. Thank you again.
    What changes came out of the meeting?

    And, more importantly, what changes are you going to make in your practice?
  11. by   SobreRN
    I hope you can stop beating yourself up, we have all made mistakes and this one will not only not ruin your career you will be better for it in the long run. Sometimes I think we go over things more when we know we are tired and/or it is very busy, you learned from of and the patient was not harmed.
  12. by   bevtag
    Forgive yourself, learn from your mistake and move on.
  13. by   jemag41
    May I ask what type of pump you were using? Because the pump I am used to only goes up to 999 mL/hour. Also, you should report this to the Institute for Safe Medication Practices (ISMP). It is completely confidential and non-punitive. You don't even need to leave your name but it helps if you do because they like to communicate with you if they have questions. This organizations studies medication errors and the "reporting" is not to get anyone in trouble but rather other people learning from mistakes in order to prevent future similar errors. Please consider! Report Medication Error To ISMP
  14. by   ~♪♫ in my ♥~
    I'll start with, "Hi, my name is KindaBack and I was involved in a serious medication error."

    So, niceties out of the way...

    You need to get clear on high-alert medications and *why* they are mandated to have an independent double-check. Heparin and insulin are the two top dogs on the list if for no other reason than we give 'em all the time. Except in an acute STEMI, heparin is not a time-critical med; there's no reason to ever, ever skip the double-check.

    This error does reveal a lack of basic knowledge about heparin as well as basic med practices. At the moment I cannot think of any medication that is dosed by volume; most of 'em are dosed by mass (mg/g) with the few exceptions such as heparin and insulin which are dosed in units. Additionally, typical heparin doses are 4000-6000 units as a loading dose and in the neighborhood of 1000 units per hour.

    Did it not trip some alarm bells in your head when your dose came out to be more than 4 bags of heparin? Very, very few meds require multiple vials to administer the dose. Getting an answer such as you did should trigger the "is this reasonable?" question for you... which is something that I urge students to apply to every answer that they get.

    I'm also a bit confused about the provider response... the patient was just loaded with dose of heparin 10x - 100x the appropriate dose and they didn't order immediate reversal and transfer of the patient to the ICU for close monitoring? Perhaps I'm misunderstanding how much heparin the patient actually received.

    Here's my advice, from someone who's made a serious med error:

    1) Learn, learn, learn... why did this happen? There are two root causes: (a) not following standard protocols requiring an independent double-check, and (b) lack of knowledge/experience with the drug. Make sure you never let either of those issues happen again. Always double-check and always be certain that you know your drug... you can't fulfill the five, six, seven, or eight rights of med administration if you're not intimately familiar with the drug.

    2) Don't beat yourself up over it. You made a serious mistake, true, but that makes you a safer nurse in the long run. I use this analogy: When I was a young pup, I crashed my motorcycle due to recklessly riding way above my skill and experience level. Afterward, when I would ride again, people would express concern about my riding. I would always reply, "Are you kidding? I'm now the safest rider that you'll ever come across because I *know* how bad it can go and how quickly." It's the same with the med error... if you do a root-cause and make the fundamental change, it's quite likely that you will *never* make another med error.

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