Med Errors

Nurses Medications

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nwrn2010

13 Posts

I am also a new graduate and I learned a lot from this post. Being new and terrified to make a mistake, I check the order at least 12 times before I administer anything. I never want to become too comfortable giving meds because it's the fear of making a mistake that causes you to exercise extreme caution.

I was pulling meds out of our omnicell yesterday and I always look at the med before i shut the drawer to make sure it is what I am supposed to be administering. It told me bin x was aricept and I pulled diltiazem out of that same bin. I called the pharmacy and we got it straight but even with a computerized system, meds get misplaced!! ALWAYS CHECK THE MEDS!!

Another incident with the omnicell and this happened to another nurse: a vial of Lasix was mixed in with the vials of heparin! Both have orange caps!!! It is so important to read labels and make sure it is correct. This nurse caught the error as soon as she picked it up but it is still scary. I know we get in a rush on the floor but we should always take time to do the 5 rights!

MissJulie

214 Posts

I'm a student nurse, and reading this thread has blown my mind! Of course, I knew that med errors happen, and even my instructors have told us they've had errors and what they were, what they did, and any repercusions (sp). Anyway, I have to say that I agree with a previous poster that questioned, "And they want to replace LPN/LVNs with CMAs, etc." Sure, LPNs/LVNs are diploma nurses and technically have less education than RNs, but they are trained and liscensed!

I actually caught an "error" if you will during clinicals a little while back. We are given the meds by the staff nurse, b/c neither students nor instructors have a password to the storage, anyway, the pt was supposed to have Digoxin. So, before getting the meds from the instructor, I went in and did vitals, HR was 80, so I went to get the meds. No digoxin in the baggie. When we questioned the staff nurse about where it was (we figured a pharm mistake, maybe), she goes "Oh, I already gave it. Did I forget to chart it?" Um, yeah! If we had had access to the storage, my instructor and I could have potentially given a second dose...

Oh, and of course we're still at the point where we have to repeat the 5 rights, except my clinical instructor requires a 6th- Allergies!

Thanks for all the free info though! :)

Asystole RN

2,352 Posts

I'm a student nurse, and reading this thread has blown my mind! Of course, I knew that med errors happen, and even my instructors have told us they've had errors and what they were, what they did, and any repercusions (sp). Anyway, I have to say that I agree with a previous poster that questioned, "And they want to replace LPN/LVNs with CMAs, etc." Sure, LPNs/LVNs are diploma nurses and technically have less education than RNs, but they are trained and liscensed!

Oh, and of course we're still at the point where we have to repeat the 5 rights, except my clinical instructor requires a 6th- Allergies!

The Arizona Board of Nursing released the results of a pilot study of "Medication Technicians" or Med CNAs in 2008, exploring the idea of using them in Arizona.

Pre Med Tech average med error rate 10.4% (LPN - 10.12%; RN - 11.54%)

Post Med Tech average med error rate 6.6% (LPN - 7.25%; RN - 2.75%; Med Tech - 6.06%)

Interesting...

I have seen the "5 rights" turn into the "7 rights" then to the "10 rights"

katebean04

70 Posts

This was told by my basic pharmacology teacher (who is a veternarian....just taking this class out of interest while on the waiting list for the nursing program.) Well, apparently someone broke into her clinic looking for oxcontin, and just saw a med with the word "oxy" and decided that they had struck gold. Needless to say, the criminal went to the ER complaining of horrible abdominal cramping.

allnurses Guide

nursel56

7,078 Posts

Specializes in Peds/outpatient FP,derm,allergy/private duty.

The 5 Rights (6?7?8? etc) apply to medication administration whether you're a student or have been a nurse for too many years to count. Sometimes I think they are actually more important for nurses who've been doing it for a looooooong time over and over as it's much easier to let your attention wander. Students are hyper-aware.

Miss Julie you bring up what is a pretty common source of error - and that's when the responsibility for pulling, giving, charting, etc is divided over more than one person. If a nurse has sole responsibility for her patient's meds and waits to chart it not much will happen as long as she doesn't report off to someone else or leave without charting it. The nurse did not adequately communicate with you and should have thought about that when she took the Digoxin out of the baggie.

Asystole that is interesting! I'd love to see that - do you have a link? It looks like on the surface it's saying that error rates dropped when they got some help - not surprising, really. But RN error rates went from 11 something to 2 something percent? That's curious.

Pediatric Critical Care Columnist

NotReady4PrimeTime, RN

5 Articles; 7,358 Posts

Specializes in NICU, PICU, PCVICU and peds oncology.

What struck me about that is that there are no stats for errors by tthe MED TECHS! It stands to reason that if the LPN/LVNs and the RNs aren't giving as many meds there would be fewer errors made. The law of averages, you know. But how about the TOTAL number of errors made psot introduction of the med techs?? (Who, by the way, would only have that one responsibility and not a hundred others competing for attention from the same brain...)

Specializes in Geriatrics, MR/DD, Clinic.

Miss Julie you bring up what is a pretty common source of error - and that's when the responsibility for pulling, giving, charting, etc is divided over more than one person. If a nurse has sole responsibility for her patient's meds and waits to chart it not much will happen as long as she doesn't report off to someone else or leave without charting it. The nurse did not adequately communicate with you and should have thought about that when she took the Digoxin out of the baggie.

I have to agree with this. The majority of med errors I have encountered recently (missed medications, not doubled doses), come from this scenario. Either a splitting of a shift or someone taking over a cart without proper communication.

catlvr

239 Posts

Specializes in Geriatrics, Hospice, Palliative Care.

Last night, I found an IV med error. I work at a SNF, and our meds come from an offsite pharm. The IVs were in a plastic bag, and the label for the ABT indicated that it was two different concentrations...it was given by four nurses before I found the error. Just goes to show...do the checks yourself, rather than rely on what others have done. You can't assume that they have all done it correctly, even though 99% of the time they have.

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