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.
Feb 19, '13
by BostonFNP Moderator
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
Feb 25, '13
by leslie :-D
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.
Last edit by leslie :-D on Feb 25, '13