I am 5 months into nursing and have made multiple errors. When I say multiple, I mean 6 total; 3 while orienting and 3 while on my own. Last night was a biggie.
I work on an very busy oncology unit in a teaching hospital with lots of interns rotating through with lots of orders issued and d/c'd daily. We still use paper MARs, much to my dismay. The first four of my errors were medications not given or not given on time. The meds forgotten were NOT chemo or anti-hypertensive meds or meds that would be life threatening not being given. I know, ANY forgotten med is a med error and I took full responsibility for each one, reported to the MD and filed the correct form for the errors.
The 5th error is kind of a long story, but to make it short. I miss read dosing instructions on a PCA order and increased the continuous without an order. I am not trying to make excuses, but in my defense, I text paged the MD and let her know pain level, interventions and my intention of increasing the demand dose an "additional 0.3mg per order" and to let her know the spouse was at bedside and wanted to speak with her. She telephoned me to state she couldn't get to the bedside for a while. Never questioned my intention to increase the PCA dose. So at shift change, the mistake was found, I was educated, contacted the MD and was told that was NOT what she wanted, filed another med error report.
This latest error has me spinning and really doubting my abilities as a nurse. Room A had a Narcan drip at 13.6ml/hr to decrease itching associated with the Fentanyl PCA. Room B had a Protonix drip at 25ml/hr for a GI bleed. I guess you know what is coming next....I inadvertently hung the Narcan drip in room 7 INSTEAD of the Protonix. So Narcan ran for nearly 6 hours at 25ml/hr. Now, I can replay everything in my head and know the steps I missed that allowed this mistake to happen.....not double checking the name/drug on the MAR to the fluid bag, not double checking the wrist band to the MAR, not making the verifying nurse actually walk into the patients room to verify the med hanging on the IV pole....6 rights of med administration blatantly not followed. The very foundation of nursing med administration! I know this!! So why did I not follow the steps and prevent this med error!!!
No harm came to the patient that received the Narcan instead of his Protonix. Which is a relief to me. I am not sure I could mentally handle knowing I harmed a patient.
I take complete responsibility for this! I feel very blessed that I still have a job! I love the unit I work on, I love the unit manager.
After 3 months of being on my own, I am being place back with a preceptor and the unit educator for two weeks. I am so nervous! I know I am human, and I make mistakes, but this is one of those mistakes I will never forget!
Not sure what I am looking for from this forum. I'm sure some of you will chew me up and spit me out regarding my mistake and a lack of judgement. I just feel so completely overwhelmed and rushed to keep up with all of the orders and medications. Nurses on my floor say it will get easier, but that light just seems so far away.
