My First Medication Error | allnurses

My First Medication Error

  1. 0 Hey everyone, I'm new to this site and I just wanted to share with you my first medication error that I made tonight.
    Tonight, I had seven patients and had begun working on the 2000 medications. I became distracted with patient number 1 and once I got out of that patients room, I began working on the medications for patient number 2. For some reason I mixed the two patients up and I gave patient number 1's heparin to patient number 2. 5000units subcut. I feel absolutely horrible!!! The patient was informed, as was the doctor and charge nurse. I was told that its going to be okay, and all that will have to be done is some PTT bloodwork. I'm feeling so incompetent and useless. I cried for a whole hour at work tonight before I could face my co-workers. Some comforting words would be appreciated...

    Thank you for letting me vent.
  2. Visit  miss_sabrina45` profile page

    About miss_sabrina45`

    Joined Mar '09; Posts: 2; Likes: 1.

    21 Comments so far...

  3. Visit  Zaphod profile page
    4
    It will be ok-it happens. Happened to me too. This is probably a good time to examine your med-pass and figure out a system to prevent it from happening. Dont blame only yourself. Perhaps your facility needs to put computer med scanning in place. There are many players in med errors.
    ARTPOPIST, martinalpn, tsalagicara, and 1 other like this.
  4. Visit  miss_sabrina45` profile page
    1
    I agree, it's amazing how quickly an error happens and your heart just sinks. I hope that everything is okay with my patient right now...I hope I can get some sleep before tonight...
    martinalpn likes this.
  5. Visit  caliotter3 profile page
    3
    You had best try to relax and get that needed sleep because you will be vulnerable to more errors if you are not at your reasonable best. Mistakes happen. At least you weren't immediately fired like happens to some, but it is in your record, so now you have to be very, very aware. Try relaxation exercises while you pass meds and gather yourself when distracted. It may take more time, but better to do things slowly than to rush into another mistake. Best wishes.
    martinalpn, AlynnSN, and marina2010 like this.
  6. Visit  CrunchRN profile page
    2
    No one is perfect & it happens to everybody. The important thing is that you learn from it and do not repeat it. Look at what contributed to it & make sure you modify whatever you need to in the future.

    And give yourself a break. Everyone screws up and most will be understanding and supportive cause they have been there, done that. Nobody understands like a fellow nurse the pressures & distractions that you labor under.

    Hugs,
    Kim
    momof2guys and martinalpn like this.
  7. Visit  NurseNathalie profile page
    1
    [color=pink]dear sabrina,
    [color=pink]
    [color=pink]i can understand how heartbreaking it is to make such a mistake but we,nurses, know how hard it is to work under pressure and to have loads of ptes to med-pass...
    [color=pink]first and foremost, forgive urself to have done so....only by forgiving urself , ull have peace of mind...and as said b4...now ull be, definitely, more careful and alert when passing meds...
    [color=pink]
    [color=pink]god blees ya
    martinalpn likes this.
  8. Visit  LindaPH2010 profile page
    17
    Consider yourself among the Elite. REAL Nurses like yourself put the patients safety at a top priority. Instead of trying to cover up your mistake or ignore it you actually cared about someone's health above your job. Every nurse makes mistakes, but the BEST Nurses will learn from them, and share them to help other nurses. I give you an A+ . You have PASSED the True Nurse Test!
    Now, Let it go and GO Forward. LindaPH2010
    Last edit by Silverdragon102 on Aug 7, '10 : Reason: TOS, pm to member
    jreynrn, martinalpn, Hygiene Queen, and 14 others like this.
  9. Visit  scoochy profile page
    6
    Quote from nursenathalie
    [color=pink]dear sabrina,

    [color=pink]i can understand how heartbreaking it is to make such a mistake but we,nurses, know how hard it is to work under pressure and to have loads of ptes to med-pass...
    [color=pink]first and foremost, forgive urself to have done so....only by forgiving urself , ull have peace of mind...and as said b4...now ull be, definitely, more careful and alert when passing meds...

    [color=pink]god blees ya

    utilizing the color pink when typing a comment is difficult to read, imo. what you typed may be very valuable to someone on this site, but for me, if i have difficulty reading it from the get go, then i will skip to the next comment.
    tokmom, Sparrowhawk, Cilantrophobe, and 3 others like this.
  10. Visit  canesdukegirl profile page
    4
    Oh my goodness, sweetheart, I know how crestfallen you must be. Medication errors happen. The fact that you are torn up about it means that you care about your patient, you care about your accountability, and you want to reach out to get more info on how to derail this problem. First of all, I think that I speak for most of the nurses on this forum when I say that you are not alone. Second, I feel confident when I say that you will be more aware the next time you do meds. You alone are your own worst critic, and you have obviously felt the weight of this error and will no doubt learn from it, and be able to use this experience to teach others the importance of medication administration. Now you must go about your duties aware and vigilant of medications and hold your head high, honey. You won't repeat this mistake. You are a good nurse for feeling such devastation for this error, and that alone tells me that you are ready and willing to be spot-on the next time you are on shift. You have done everything that you should have done in light of this mistake. Kudos to you for acknowledging the mistake and taking the steps to rectify the mistake. The most important thing you can do now is to forgive YOURSELF.
    Last edit by canesdukegirl on Jul 28, '10 : Reason: misspell
    martinalpn, tokmom, jxRN, and 1 other like this.
  11. Visit  jxRN profile page
    1
    we are humans, and we make mistakes. don't tear yourself up over it. i've known couple nurses who make mistakes, and some does not even want to owe up to it-- even after being confronted. By the end of the day, no one is really hurt, and it tested your morale. it'll make you become more vigilant.
    martinalpn likes this.
  12. Visit  NurseNathalie profile page
    0
    dear sabrina,

    i can understand how heartbreaking it is to make such a mistake but we,nurses, know how hard it is to work under pressure and to have loads of ptes to med-pass...

    first and foremost, forgive urself to have done so....only by forgiving urself , ull have peace of mind...and as said b4...now ull be, definitely, more careful and alert when passing meds...

    god blees ya
  13. Visit  BluegrassRN profile page
    1
    Learn from your mistake. Look at what you did wrong, and how you'll avoid making this error in the future. It is so terrifying and disheartening to make errors like this; but if you can learn from it and improve your future practice, you can take something positive and good away from this.
    martinalpn likes this.
  14. Visit  newnurse1210 profile page
    0
    Sabrina,
    I know how you feel. I am a new nurse (graduated May 2010) and I just made my first med error. I feel awful too, but keep telling myself that it'll pass and hopefully not happen again.

    Since I've been in a dull mood since it has happenend I thought I'd share it with everyone. I hope everyone learns from my mistake, i sure have.

    So yesterday I worked a 12 hour shift, it was my third day off of orientation on a Medical Floor. It was just about the end of my shift when the CNA called to inform me that my pt (new admit in ARF-- that had been gone for a few hours at tests) had just gotten his food tray and had a blood sugar of 40 (asymptomatic) and a blood pressure of 71/45. I called the other RN I was working with (we work in teams) and she talked to the Dr who ordered a fluid bolus and an amp of Dextrose 50% IVP. I removed the D50 from the accu-dose machine and took it into the room to verify it with the MAR. The MAR said for 1/2 amp give 3 ml over at least 1 min. I was in a hurry and misread this thinking the 1/2 amp over 3 minutes so I gave the full AMP over 6 minutes. I think I misread this because the only other time I gave it was when I went on an ambulance run as a student and the paramedic had me push D50 instructing me to push it in as fast as I could. The sad thing is that I wouldn't even have realized that I had done something wrong because the other RN came and asked if I gave the D50 already and she was surprised to find out that I was already done with it considering its supposed to take 18 minutes! When I found out, I had a hard time believing her considering my experience on the ambulance run, and then I looked back at the MAR and my heart sank.

    After I gave the medicine the pt, telemetry called saying that my pt was having some ST depression. The MD had me do an EKG which was fine and the pt didn't complain of any chest pain. After this I filled out an incident report. The nurses I worked with at first didn't think I should even fill one out (admitted to having given this faster than they should also), but then they thought I should in case something would be made of this. I feel so bad, I try so hard to try to be safe and double check things and then I do somethign like this. I hope nothign happened to the pt after I left. I haven't heard anything from my boss yet, but I wonder what is goign to be made of this...


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