Multiple medication errors

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    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.
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  3. 19 Comments so far...

  4. 2
    It sounds like you have had a rough road that past few months; on the bright side, it sounds like you have always been honest and up-front about your errors.

    I would suspect that you may be a little over your head on your current floor and the result is an unsafe practice environment.

    How would you feel about changing your environment to one you can practice more safely in? One with a slower or more palatable workflow or with a EMR?

    I doubt anyone in this forum can say they have never made an error; I have made them as both an RN and as a NP. You have had a string of them in your current environment and, if it were me, I would worry that a lethal mistake was looming, and be looking to change.

    EDIT - I just re-read your last error. That one really concerns me because there were a number of dangerous mistakes, including a verification that did not actually verify the med admin.
    Last edit by BostonFNP on Feb 19, '13
    jadelpn and poppycat like this.
  5. 0
    I completely understand what you are saying and your concern. I am not sure where I would go for a slower pace at this time, so early in my career. I hope to go into the home health/hospice environment after 1-2 years. The other thing is my family and I are in the process of relocating to be closer to the hospital. I currently live over 1 hour away. On another note, we are moving to an EMR system in June. The entire hospital system will be moving into the Epic software. I feel like that will alleviate a lot of med mistakes...my mistakes in addition to other's.
    Thank you for your reply.
  6. 1
    Chasity2945,
    I have been a nurse for 25 years. The last 3 years have been difficult for me because my husband was sick and my focus was not
    what it should have been. I ended up having depression because this time was so stressful. I made medication errors over the last 8 months; none were life threatening, but med errors all the same. I might also add that the job that I had; I had worked for them for 23 years. I was terminated for these med errors. I had to work thru the guilt that comes with making errors, as you probably are now. I did cry for a while, but then you move on. I am a good nurse and have been one for so many years before this. You are a good nurse because you care enough about your patients that you self reported and that is someone who is a good nurse. You were honest and that is vital to be a nurse. I know you have not been a nurse for long. My advice, move on and be thankful that your employer is working with you to become a great nurse in the future. Stay in the moment always and remember that you do know what you are doing. I know that it is anxiety provoking administering meds, but as long as you follow the med rights; you will be fine.
    Don't beat youself up and ask for help when you really need it. Good luck and welcome to the nursing profession.
    Chasity2495 likes this.
  7. 1
    You must have some redeeming qualities or they would not have given you the opportunity to work with a preceptor/educator to improve your skills.
    Use them!! See what they do, and how they do it. Do NOT rush. Review your orders, what you have, what you need. Have your information, have a plan, use whatever paper brain, notebook, clipboard, pen color, highlighter that you need to.
    Take this time to re-learn your organization skills, your plan for the day, your medication administration.
    If you are feeling overwhelmed/depressed/anxious and it is impeding on your work ethic, get into some counseling! You need to take care of you first and foremost.
    Best of luck, and let us know how it goes!
    Chasity2495 likes this.
  8. 1
    I did the same exact thing and we had computer system. I inadvertently switch antibiotics for patients. Lesson learned. DO NOT EVER HOLD 2 DIFFERENT PATIENTS MEDICATION WITH YOU, including your pockets. If it is an important medication and I do not have room for error, I tell people including pt that I need to get this med a pt. I know that giving meds not on time is a medication error but my first goal is safety.
    I also went to re-preceptor but this time, our nurse educator followed me. I have reigns to all the decision making for my pt but she gave me advice to be better organize.

    I agree with everyone. A good brain sheet is important. I could not find a good one, so made one for myself that I can understand and read in a glace.

    In school, we do a lot of those stupid prioritization questions, when you are overwhelmed, instead of looking at you pt as human beings, think of them as prioritization questions. Example that day i have 4 pt bed 1- hx of CHF, c/o SOB, bed 2- a pt that is a discharge bed 3- pt in pain, bed 4- hang meds. I say it out loud so I can hear myself think and go from there. Just remember safety...it will click
    jadelpn likes this.
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    Thank you all for your encouraging words and advice. I have 3days off before my first re-orientation day. I try to stay busy with packing and preparing for our move next week. If I don't, then my mind wanders and I replay the error over and over. I cry, I feel completely overwhelmed with guilt. I know this is a learning milestone in my career, and it will get better and I will move on....but in this moment I feel awful. The questions of why I didn't do this or didn't do that constantly parade through my mind. I am nervous about going back into work.
    ARTPOPIST likes this.
  10. 0
    Don't be nervous, be determined. Be organized. Be confident in the fact that you will learn a new and better way to do your job. Because you will.
  11. 1
    I wanted to ask - Is there anything consistent about your med errors? Do you make a certain type of error, or moreso at a certain time of day, or with particular meds, whatever. Is there some pattern? If you can narrow it down to one aspect of the process that seems to be the place you are getting tripped up then sometimes its easier to come up with a plan to fix it.

    For me, that's kind of a general tool if I'm doing poorly in some area. I try to find any common denominator(s) so I can focus my work on that particular aspect.

    Also, with employers, if you can narrow it down and show them that you see that you've been having a problem with xyz part of the process and to remedy it you have decided to abc (then ask for their additional input on ways to minimize errors in that aspect of the process).
    leslie :-D likes this.
  12. 0
    Quote from Chasity2495
    ...6 rights of med administration blatantly not followed.
    is this the crux of your errors...that you haven't been following the rights of med admin?
    i am seeking to understand, and think the pp had very wise advise in encouraging you to truly consider the source(s) of your mistakes.

    as for your telephone conversation with the dr re demand dosing, i know you told her pt's husband wanted to talk to her...
    but did you ever ask her to confirm the order you desired for your pt?
    i guess i am not understanding why you would essentially 'prescribe' a med w/o implicit authorization?
    again, i seek to understand your thought process, since it seems to negate everything we were taught in nsg school.

    i am glad your employers are being supportive of you.
    whatever refresher education you may receive, the bottom line is the "aha" moment needs to come from you.
    only then will you take the necessary steps in 'redeeming' yourself in ensuring these type errors do not reoccur.

    best of everything, op.
    it does get better.

    leslie
    Last edit by leslie :-D on Feb 25, '13


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