Med Error.

Nurses Medications

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Specializes in Cardiac TCU /tele/SDU.

Im a nurse in cardiac tele/TCU

I made a med error, A heparin drip was started, and depending on the hep uf/anti-xa ( lab value) its suppose to be changed/titrated/keep the same depending on the lab value, the pharmacist is the one adjusting these but I got the order and should've recognized that he was using a wrong parameter(its in our MAR) before carrying it out. So know the patient got less of what he was suppose to have, it was caught that day,there was no harm to the patient the drip was stopped the day after as he reached the desired INR.

This is my third med error, first two were about 2 and a half years ago. my manager was really upset at those errors she was red and she was yelling. she made me do projects and present to every staff. now i have to talk to her again, Im afraid that she will let me go. I don't think I'm a bad nurse, I really care about my patients and am very diligent. I just don't know what happened. I hate myself for it, and my confidence is shot.

Am i going to be let go? what do you think? those first 2 errors were when I was new nurse to the floor.

"should've recognized that he was using a wrong parameter".

Please clarify... do you mean the pharmacist? If so the pharmacist made the error.

Specializes in Hospice, Geriatrics, Wounds.
"should've recognized that he was using a wrong parameter".

Please clarify... do you mean the pharmacist? If so the pharmacist made the error.

Not if the nurse administered.....

I wish you the best and hope your manager is understanding. We are human, not perfect by any stretch of the imagination. Errors happen....its just life. If she does fire you, consider it a new chapter in your life (I know, easier said than done). I found my dream job after being fired. Was really upset for a long time, but realized it was meant to be. I'm soooooooooooooooo much happier now!!!!!

Hugs & prayers

Specializes in Emergency Nursing.
Not if the nurse administered..... I wish you the best and hope your manager is understanding. We are human not perfect by any stretch of the imagination. Errors happen....its just life. If she does fire you, consider it a new chapter in your life (I know, easier said than done). I found my dream job after being fired. Was really upset for a long time, but realized it was meant to be. I'm soooooooooooooooo much happier now!!!!! Hugs & prayers[/quote']

It seems as though The pharmacist and the nurse both made the error. The pharmacist either made a dispensing error or a transcription error depending on the specific circumstances. The nurse made an administration error if they were responsible for verifying the dose was correct/safe dose and it was not. For argument sake say the nurse administered Tylenol 325mg for a fever because that is what the order in the computer said and the pharmacist had actually transcribed the doctors order for Tylenol 650mg incorrectly. Did the nurse actually make a med error because the usual dose is 650mg? If the nurse gave 6500mg because the order in the computer said so, I would say yes that is an error because the nurse should know that dose is not safe, but an under dose that was a written order? I feel like there is some grey area there and at the very least the nurse is not solely liable.

Specializes in ED; Med Surg.

We have a double check system for Heparin and Insulin; we look up the labs ourselves, go to the "calculator" in our protocol. The other RN looks at it with us, checks the pump settings after the change, and signs it off on the MAR. Really helps prevent things like this from happening. Hugs to you.

Specializes in Critical Care, Education.

Have you analyzed the issues behind your med errors and changed your behavior accordingly? For instance, if you are rushing through the process & not taking time for the '5 rights', you probably need to deliberately slow down & remove yourself from distractions. None of us is perfect. People who learn from their mistakes have the potential to become experts. People who do not learn from mistakes just keep on repeating "year one" over and over again.

Specializes in LTC, Psych, M/S.

It could be that you are working in an unsafe "system." I don't see why you have to take a the blame.

Specializes in Emergency, Telemetry, Transplant.

I don't really like when these discussions turn into "who is to blame?" but that seems to be where this one is going. I think both the nurse and the pharmacist is at fault. I'm not sure of the exact system your hospital has in place, but let's say that the pharmacist gets the lab result and makes a communication of adjust the drip by X" (or "keep the drip at the same rate"). Then the pharmacist is at some fault for the error. I think this is also a system error, as this doesn't seem like the best way of doing things.

However, it is also partially the fault of the nurse who is actually adjusting the drip. Not be "high horse" about it, but if I am adjust a drip of a "high alert" med, I am going to make sure that the correct adjustment is being made based on the lab work and the clinical picture.

Specializes in Anesthesia, ICU, PCU.

Is this even a med error? I could understand if you gave the person an insanely high amount of heparin and they bled, but too little and they have to be on the drip longer before they can transition AC? It seems excessive to call that a med error. People are sub-therapeutic with the ordered nomogram where I work all the time - it's just the way it goes. I know if you look at it per the nurse's 5 rights, it was an error. Looking at it from a medical standpoint, I don't think you affected the patient that adversely.

I have heard of hospitals where heparin drips are completely managed by physicians. They order the bolus (if needed) and initial rate. They order the regular PTTs and call to make sure they've been drawn. Then they check those values and call to be sure the rate is changed, per the calculations they do on their own. A union hospital this is.

Where I work the nurse does it all, even so far as reordering PTTs q6h (with physician cosign required), looking up values, calculating rate changes based on previous rate and patient's weight, and then making those changes with a witness RN to check all of the above.

Specializes in NICU, PICU, Transport, L&D, Hospice.
I don't really like when these discussions turn into "who is to blame?" but that seems to be where this one is going. I think both the nurse and the pharmacist is at fault. I'm not sure of the exact system your hospital has in place, but let's say that the pharmacist gets the lab result and makes a communication of adjust the drip by X" (or "keep the drip at the same rate"). Then the pharmacist is at some fault for the error. I think this is also a system error, as this doesn't seem like the best way of doing things.

However, it is also partially the fault of the nurse who is actually adjusting the drip. Not be "high horse" about it, but if I am adjust a drip of a "high alert" med, I am going to make sure that the correct adjustment is being made based on the lab work and the clinical picture.

Of course it comes down to "who is to blame", the nurse will at minimum be reprimanded and at worst be terminated because she "is to blame" and will be held accountable.

What would be more constructive would be a discussion of what processes lead to the error with the goal of improving the processes.

How does it work where you work?

Specializes in Emergency, Telemetry, Transplant.
Of course it comes down to "who is to blame", the nurse will at minimum be reprimanded and at worst be terminated because she "is to blame" and will be held accountable.

What would be more constructive would be a discussion of what processes lead to the error with the goal of improving the processes.

How does it work where you work?

I very much agree that the discussion needs to be about why the error was made, not just which person made it. Who orders the lab draw? Does only the pharmacist get the result? If the nurse gets it to, he/she should be on board with any rate changes.

Also, are you asking how med errors are investigated at my hospital? I don't know. Thank the Lord that I have never been the target of said investigation. Also, if the nurse in question has made multiple med errors, I would imagine that, fair or not, greater scrutiny is going to be focused on that nurse. Hopefully such scrutiny will center on "what can be done to help the nurse prevent errors in the future"; not "let's hang this nurse out to dry."

Specializes in NICU, PICU, Transport, L&D, Hospice.

well, I guess I was asking anyone/everyone as not all employers handle these issues the same way.

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