Terrible Medication Error

[rekea526]

I made the worst medication error today and feel so horrible about it. I literally wanted to quit the job from sadness and embarrassment. I'm a new nurse and have only been working at the hospital for about 5 months. I've been a nurse for about 10 months.

I had a patient on a Lasix drip that was 100ml total volume. 100 mg in 90ml which calculated out to be given 5ml/hr. This may sound confusing but long story short I infused the medication at 100ml/hr instead of 5ml/hr because I was looking at the 100mg in 90ml and I was also looking at the 100 ml total volume instead of paying attention to the 5ml/hr like I should have. I and the charge nurse caught the error but 75ml had already gone in a little over 3 hrs when this medication should have lasted for almost 20 hrs if it was done correctly.

We contacted the doctor he said to just monitor him, I filled out an incident report, and we restarted the infusion at the correct dose. I believe I got confused because of all the different numbers on the IV bag and I was also very busy that night. The result of this was critical potassium of 2.1!! we luckily had a potassium protocol to start potassium IV 50ml/hr for 6 bags total and recheck the level. I felt humiliated!! and so embarrassed.

I knew everyone had known my mistake because a random nurse came to me and asked me if I was ok. I knew he was asking this because the charge nurse must've told him what happened. I feel so dumb and incompetent as a nurse. I don't know how I will face this at work tomorrow. Not to mention we do this thing called line up at the start of shift where we discuss things that are going on in the hospital and on the unit and we talk about bad mistakes that nurses make throughout the hospital. I'm sure this is bad enough to be talked about during line up.

Although they don't say the name of the person who made the mistake I know everyone will know it was me, and of course, I will know it's me they're talking about! What makes it even worse is they read the same scenarios in a line up every day until a new situation happens that they can add to the lineup discussion. I will be so embarrassed every time they talk about this in the lineup. How do I come back from this? I feel like the worse person and nurse ever. I can't even think straight. I still don't know what penalty I will face yet but I'm praying I don't get fired.

Lastly, the worst part of this situation is. When it was time to hang the potassium my charge nurse caught me off guard because I was already anxious and nervous and asked me what I would run the potassium at if it was 50ml per hr, just to be sure I would hang the IV correctly. I accidentally said 25ml instead of 50ml because I get so nervous when I'm caught on the spot and asked questions. I'm sure she thinks I'm a complete idiot. I feel like my life is ruined!! IDK what to do. What if nursing just isn't the profession for me after I've worked so hard for it, I'm so distraught!

[Esme12, ASN, BSN, RN]

We all make mistakes. You are saving your co-workers from repeating the same one. Hold your head up and help teach others how you have learned from this experience (nightmare as it feels right now).

Take a deep breath and hold your head up and tell them what you learned from this....your career isn't over. ((HUGS))

[lagalanurse]

I gave 100mg IVP yesterday, so I'm not understanding why this is so bad. Did one dose of Lasix bring a K level down THAT much or did this pt have a low K level already?

[monkeybug]

You really sound like you need a hug! Take a deep breath, I promise it will get better. It should be some consolation to you to know that you will probably never, ever make a mistake like that again. I look back on some of the errors I made and I still cringe. We expect perfection from ourselves, and that's never going to happen. Do your best, check yourself, be careful, and realize that, in the end, no one was harmed. As for the line of shame, or whatever it's called, you said that until something else happens, your mistake will be discussed. Just think, when something else occurs, it's another nurse beating herself up and making herself miserable.

[MadpeysRN]

Hesitate before you medicate!! I am always so hesitant when I start an Iv that I check the dosing about 5 times before I hit start. I'm only a nurse for 4 months so far.

[eyesopen_mouthshut, CNA]

Honey don't worry. Yes, you made a mistake. But you are human, and you are a nurse, which makes you a superhero-- and superheroes can't always get things 100% right, especially if they've only been saving lives for 10 months. Let this be a learning experience for you, something you will carry with you to teach to new nurses you will be in charge of training. Just look in the mirror and forgive yourself for your mistake, and move on. I know how hard it is to deal with med errors. I was a pharm tech before and during my time of being a CNA, and I can't tell you how many times an accident happened. But these are things we will always remember, and in truth, it helps us become better because WE NEVER WANT TO DO IT AGAIN!

Just hang in there, and talk to your DON if you're still nervous. I'm sure s/he will tell you about when they were new nurses and mistakes they made and how they learned from them.

Don't let this discourage you. You made it through nursing school! You passed your boards!!! Not just anyone can say that. You are a superheroine, don't forget that- you made a mistake, and you're woman enough to admit it. Be strong, and remember how bada** you are.

Keep us UTD on what happens, and know that this community is here for you! We all support our own ? /hugs/

[asantewaa13]

This too shall pass. Just remember that and I pray God gives you the peace of mind you need. ?

[Michele23]

You have received a lot of supportive comments and I wish I had come here when I first became a nurse 3 years ago ? I was trained in my LTC by a friend/RN on the midnight shift, and the way they did it was to sit at the desk and pre-sign and flag the MAR. I was brand new, not used to reading a MAR, and as a result, I neglected to give antibiotics quite a few times. They are usually newer orders written on the last pages. I was called into the DON's office every time & always walked out feeling like a complete idiot. My DON kept stressing to me to sign the MAR 'after' I gave the med and I did start to do that even though it was more time-consuming. I didn't know at the time that I had been inadequately trained. I do now. Good habits from the beginning make a world of difference. Of course, now I am extremely diligent with my MAR, but I still wish I had been trained that way and I make sure when I train new nurses that I stress the importance of double/triple checking every page. You will get through this, trust me, it will make you more diligent about every med you give. I've been there. I was humiliated and crying years ago, and because of that I am very compassionate with new nurses and I share my secrets with them so they don't make the same mistakes. (hugs) to you and just remember this too shall pass!!!

[ARTPOPIST, ASN, RN]

Whoops! Accidentally posted twice, so look at the next post for my experience.

[ARTPOPIST, ASN, RN]

I was thinking about starting a new topic, but then I saw this thread! It's been a while since someone's posted in this topic, so I'll just update it with my horrible experience today ? (this might end up being long, but we'll see!)

Anyway, a little background about me: I'm a brand new RN. Got my license in September 2013 (on my 21st bday :)). Started my first job as a real nurse in January 2014 (last month), and have been on my own since about 2 weeks ago at a long term care facility. The patient ratio is about 30-35 patients for me (sounds ridiculous, but I recently found out that it's typical for long term care nurses lol).

Here's a summary of my horrible experience today: I'll try not to type a long novel about what happened, but I basically gave a bit too much insulin to one of the residents. The resident turned out fine. Administered glucagon and monitored closely. Rechecked B/S and it was fine, resident became more alert, and was pretty much stable by the end of my shift.

Now I'm the type to accept ALL of my mistakes. I never act like I know everything and always tell myself that there's always more room for learning. SOOO with that said, I forgot about what just happened and focused more on finishing my work for my shift. I decided to save the water works for when I got home, where I COMPLETELY broke down. Every insecure thought you could imagine ok: How stupid can you get, Did you even learn anything in nursing school, You could've killed someone, Do I even deserve to be a nurse, I deserve to have my license taken away, etc. because of how stupid of a mistake it was.

I'm okay now though (somewhat). It's amazing what crying can do I OBVIOUSLY need to read up on insulins...something I've always been a bit iffy on. Also, to NEVER rush with giving meds even IF you have so many patients and want to get done on time so badly. I'm aware that EVERY nurse (or maybe like 90% at least lol) has their own share of terrible mistakes as a brand new nurse. I guess I'm just curious to see if anyone else has suffered a really dumb mistake as I did. I haven't read this entire thread yet, but I definitely will just to see if anyone is feeling the same way I currently do after my bad experience. I'm also very curious if you guys have ever come close to, or actually MADE, a med error, due to for example Insulin Order had "u" written in the MAR instead of "units," etc. OR if you thought an order said one thing, but it was actually another thing...something like that lol.

And if you care enough to share any repercussions from said bad experience, please do so (and thanks in advance for being brave enough to share)! I don't ever judge and I hope none of you either ? Just share any story pertaining to terrible errors LOL as I'm more than willing to listen/read to get over my terrible experience.

Ok, I'll shut up now. ? It's 2014 haha. Please, keep sharing my fellow nurses!

[akulahawkRN, ADN, RN, EMT-P]

Even I, with all the protections of nursing instructors around, have made a med error. Did I make an error that would have resulted in harm to the patient? No. It was an error though and I learned a LOT through the process of going through WHY I made the error. Consequently, I've become a LOT more careful about the meds I do give. Remember, some of the meds we give have the potential to kill the patient if not given correctly, and what's worse, just like a fired bullet, you often can't reverse what you've done. The faster you go, the faster you can cause an error and not catch it.

[ARTPOPIST, ASN, RN]

Michele23 said:

You have received a lot of supportive comments and I wish I had come here when I first became a nurse 3 years ago ? I was trained in my LTC by a friend/RN on the midnight shift, and the way they did it was to sit at the desk and pre-sign and flag the MAR. I was brand new, not used to reading a MAR, and as a result I neglected to give antibiotics quite a few times. They are usually newer orders written on the last pages. I was called into the DON's office every time & always walked out feeling like a complete idiot. My DON kept stressing to me to sign the MAR 'after' I gave the med and I did start to do that even though it was more time consuming. I didn't know at the time that I had been inadequately trained. I do now. Good habits from the beginning make a world of difference. Of course now I am extremely diligent with my MAR, but I still wish I had been trained that way and I make sure when I train new nurses that I stress the importance of double/triple checking every page. You will get through this, trust me, it will make you more diligent about every med you give. I've been there. I was humiliated and crying years ago, and because of that I am very compassionate with new nurses and I share my secrets with them so they don't make the same mistakes. (hugs) to you and just remember this too shall pass!!!

Not sure if all LTCs are the same, but I'm right there with you on the pre-pulling meds, pre-signing, and flagging!! I've always wondered how the nurses got done on time. Then they showed me this iffy technique LOL. It's so time-consuming when you have 25-35 patients though. And even IF I DO pre-pull, pre-sign, etc., I STILL get a little behind on my med pass! It's funny though; I was in such a rush today and had to change O2 tubings and neb masks for every patient that had one in the middle of the night, so I didn't get to pre-pull OR pre-sign ANYTHING. So I went through every patient's MAR the correct way during my med pass and actually finished almost an hour early!! Just in time to catch my med error too and monitor one of my residents (mentioned 2 posts before this) and I DO believe God sent my guardian angel back to visit me today to give me enough time to catch this error and stabilize the resident. That angel tends to visit me frequently.

[dudette10, MSN, RN]

I gave 100mg IVP yesterday, so I'm not understanding why this is so bad. Did one dose of Lasix bring a K level down THAT much or did this pt have a low K level already?

I want to know the answer to this question too! I push 80 mg IV on my new admit CHFers all the time! What disease process or situation would require a Lasix drip that slow?