Terrible Medication error - page 2

by rekea526 40,388 Views | 38 Comments

I made the worst medication error today and feel so horrible about it. I literraly wanted to quit the job from sadness and embarrasement. I'm a new nurse and have only been working at the hosiptal for about 5 months. I've been a... Read More


  1. 4
    I knew an experienced nurse who was hanging a cardizem drip. It had 125 mg in 125 mL D5). For the dose, rather than entering the correct value (10 mg/hr, which would be a rate of 10 ml/hr) she entered the volume to be infused (125 mL). So the pt got all 125 mg of cardizem in one hour. Thankfully, no harm to the pt. The point is, this error was a "biggie" made by an experienced nurse. It happens. You learned your lesson, now move on and make sure to carefully check those drips.
    ARTPOPIST, Sugarcoma, SoldierNurse22, and 1 other like this.
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    You learn and move on. It's ok. The patient is ok. I know it's embarrassing, but you did the RIGHT THING by self reporting and putting the patient first. Good job! People will forget about it sooner than you think. The bet thing to come out of this is this: someday you will be orienting a new grad nurse, and will be teaching them about always always having someone double check your drips, or any high risk meds. And you can tell them your story.....they can learn before making the mistake themselves. Nurses are human.....you made a mistake, but you did the right thing to fix it.
    just.me, Sugarcoma, and SoldierNurse22 like this.
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    HUGS to you... listen, everyone makes mistakes... just last weekend at work, a experienced nurse gave a medication in the am, that was written for pm... it happens!!! the patient is fine, you owned it right away, it doesnt make you less of a nurse..it makes you human... and i would bet my life that you will double and triple all infusions from here on it... try to relax now!
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    depending on the specific degree of med error, our facility makes the rn go to a quality assurance briefing.
    you said that they labels are hard to read?

    maybe this is something you can bring up in a quality meeting. it is not making excuses, if you earnestly believe the labeling is confusing. perhaps it is.
    perhaps you need to focus more intently. who knows. thats why its a r e v i e w :-)
    best of luck,
    ARTPOPIST and Sugar Magnolia like this.
  5. 13
    You all stand around at the start of the shift and discuss evetyone who's made a mistake? That sounds just plain horribke and doesn't serve any purpose. Learn from your mistake, be thankful no one was harmed, and move on.
    NightOwl0624, icuRNmaggie, just.me, and 10 others like this.
  6. 3
    Stop beating yourself up. We have all made mistakes and the best lesson out if it is we will never make that mistake again. Don't worry what others think and this is a benefit to your peers to hear of errors. We often get lazy and at times cocky we need these lessons learned as a way for us to be paying attention.
  7. 14
    The only nurses who say they've never committed a med error are either fresh out of school, or lying.

    Also, there are two kinds of nurses: the kind who've made a med error, and the kind who will.

    Learn from this, and move forward. You did all the right things in following up on your mistake, and the patient is OK.......it could've been a lot worse if you hadn't caught it as quickly as you did. You did fine. And I think it's a safe bet that you'll never make another one like it.
    redmielita, icuRNmaggie, systoly, and 11 others like this.
  8. 2
    I've seen patients get 80 mg IV lasix as an IV push, given over oh, ten minutes or so... Of course for those patients there was backup potassium ordered. There should have been as well, for your patient on a lasix drip. It takes a day or two to get over the adrenaline rush (bad rush, it's scary as heck) of a med error but just analyze, remember how you made the mistake and avoid doing that again. You are doing fine. You caught it, figured it out, reported it, fixed it, didn't kill the patient, and the next step is to go back to work and hold your head up, and just work. It'll be all right in the end.

    I misread a computer printout from a dinosaur system when I was brand new, checked it twice with my preceptor, and gave mag citrate to a dude who was only gonna have an upper GI and only needed to be NPO after midnight. What a fun night. Lesson learned: don't be in too big a hurry to make someone poop all night, make sure they REALLY need it first. I was embarrassed, the patient was 10 lbs lighter in the morning, but it all worked out.

    Edit to add: they fixed the computer instructions very shortly after that.
    icuRNmaggie and sapphire18 like this.
  9. 1
    We all do it. Some nurses say they have never made a med error - I guarantee if they have been a nurse very long they have made some type of med error. Either they are lying (which I hope not), or they didn't catch the med error. Example - an antibiotic was due at supper for a patient and they got two capsules. I only gave them one, and had no clue I had made an error until the next day when I worked and saw that the patient was to receive two capsules - that is when I realized I had only given them one capsule the evening before. Had I not worked that second day on that same unit, I would have never known I had made the med error.

    If it makes you feel more comfortable, double check the rate on your IV bags with another nurse until you gain your confidence back. Yes they will all talk about you - mostly because they are breathing a sigh of relief it wasn't them that made that particular error, but you can bet at some point most of them will make one.

    I do think it is a good idea to discuss mistakes made as it can help other nurses from making the same mistake, but I think they can present it at a different time and in a different manner, use it more as a learning tool.
    ARTPOPIST likes this.
  10. 2
    Quote from Indy
    I've seen patients get 80 mg IV lasix as an IV push, given over oh, ten minutes or so... Of course for those patients there was backup potassium ordered. There should have been as well, for your patient on a lasix drip. It takes a day or two to get over the adrenaline rush (bad rush, it's scary as heck) of a med error but just analyze, remember how you made the mistake and avoid doing that again. You are doing fine. You caught it, figured it out, reported it, fixed it, didn't kill the patient, and the next step is to go back to work and hold your head up, and just work. It'll be all right in the end.
    This, that's a bolus for some of our CHFers. Didn't your nursing instructors ever tell you you weren't going to be perfect as a new nurse. I know mine made it very clear to us that mistakes will most likely happen at some point.

    They may pull you aside to talk about it, to see if there was a "procedural" error (i.e. the difficult to read IV bag). And you may get a ding on a review, but again you are a new nurse and no harm came to the patient. They aren't going to fire you over one error, it's only an issue if they start to pile up, which after this, I'm sure they won't


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