Terrible Medication error - page 3

by rekea526 36,721 Views | 36 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


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    Anybody who say they haven't made a mistake are normally lying, told to me by matron when I have the wrong patient beta blocker, the embarrassment will go away, in the lineup you should declare its you seeing as though they already know, explain what happens how they mistake came to be and explain also how you feel, it's a learning experience for you all. But mostly don't beat yourself up about it, you feel bad... It would be so much more worrying if you didn't care, and most important thing patient fine.
    PatchycatRN and Sugarcoma like this.
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    Quote from rekea526
    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 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 l00mg in 90ml and I was also looking at the 100 ml total volume instead of paying attenion to the 5ml/hr like I should have. Me and the charge nurse caught the error but 75ml had already went in 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 belive 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 a 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 embarrased. I knew everyone had knew 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 tommorow. Not to mention we do this thing called line up at the start of shift where we discuss things thats going on in the hospital and on the unit and we talk about bad mistakes that nurses make through out 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 their talking about! What makes it even worse is they read the same scenarios in line up everyday until a new situation happens that they can add to the lineup discussion. I will be so embarrassed everytime they talk about this in 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 accidently 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!


    Oh my goodness! Take a deep breath! You made a medication error -- everyone makes them. This wasn't the worst medication error that you could have made, and it sounds as if the only injury was to your pride and not to the patient. That's a good thing! You caught the error and immediately reported it then set about doing what you could to mitigate the damage to the patient. That's what you're supposed to do. Presumably you've also learned from your mistake.

    Everyone makes mistakes. Absolutely everyone. If you ever find someone who says they'v never made a mistake, they're either lying o you or complete idiots who haven't realized they've made a mistake. This is not the end of the world. You'll get over it. In the meantime, focus on the positive. You made the mistake, but you recognized it admitted to it and then started to mitigate the damage. You did what you were supposed to do. Good on you!.
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    Recovering from a medication error will take some time. It is a shocking experience that causes a lot of self doubt. The feelings you are experiencing right now are perfectly normal. The key is to not let this anxiety and doubt paralyze you. We have all had experiences in our life where we make one error and then it seems to snowball...with the anxiety contributing to even more errors. You reference this in your post when you speak of the potassium. For your situation this is bound to be magnified by the thought of everyone discussing you, analyzing you etc. etc.

    First know that what the previous posters have said is absolutely true! Every nurse new or old makes an error. It is part of being human. Some of us may have been lucky enough thus far in our careers, to not have made a very serious med error, not because we are some super awesome nurse, but because we have been lucky. But for the grace of god go I........ this is so very true!
    This one error does not make you a horrible nurse or mean you are not cut out for this job! I would be very surprised if you were fired for this error.

    You may find that you need a day off to process this. Do not feel bad if you do. Going straight back the next day after making an error may be too much for you. If you find this is true, call your manager right away and discuss this with him/her. When you do return know that people will absolutely talk about this. They always do. Most of us discuss med errors made by others not out of maliciousness but because we want to prevent it from happening to us. There are a small percentage of those who take glee in others mistakes. Those people are not worth your consideration. They use other peoples misery to make themselves feel superior. Recognize this for what it is...a sign of insecurity that is not reflective of you at all. They would do this to anyone who made an error!

    What you can do for your own professional growth is really analyze what you feel contributed to this error. You mentioned you were rushed and that the IV bag label confused you. What other factors do you feel contributed? Ratio? Acuity of pt.s? Unfamiliarity with the medication? Are you under stress at home? etc. You may find through your self reflection a systems error that could help make your facility safer in the future. One that I see right away from your post is the medication label. When we generate a label for a drip, even a titratable one, we have to put in the starting dose it is ordered at. The label will then tell us the rate the drip should be infused at for that dosage. A second issue that I see is the IV pump. Is it a smart pump? The pumps that we use would not have allowed us to program an infusion of Lasix for this rate. If you hang a lot of potentially dangerous meds this may be something your unit might benefit from. Perhaps you could bring these points up during the "line-up."

    Do not feel embarrassed when this is discussed on your unit. It would have been very easy for you to have covered this error up had you really wanted to. It takes great bravery, and shows a true concern for your patient's well-being, to fess up and deal with the fallout. Many people hide their mistakes! I would be real tempted to say "Hey guys I am that Lasix nurse and this is what this error has taught me" during the line-up. Hold your head up high when you return to work. Aside from never making an error at all you did the best possible thing: minimizing the potential damage by admitting to what happened and alerting the physician.
    Last edit by Sugarcoma on Apr 18, '13 : Reason: spelling
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    Ahh .....a med error...is a HORRIFYING experience!!!!

    You cannot undo it and you have to sit back and make a plan to NEVER do that again.

    But the important thing here is this: You quickly realized and rectified your error.

    You need to remember that you are not the first, nor the last to make an error. Take the opportunity to work with the hopsital on fixing the label issue. Maybe be a perfect way to help you see that good can come out of a "Human" mistake.

    Hugs!
    ARTPOPIST, PatchycatRN, and Sugarcoma like this.
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    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))
    ARTPOPIST and Sugarcoma like this.
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    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?
    dudette10 likes this.
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    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.
    ARTPOPIST and eyesopen_mouthshut like this.
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    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.
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    Honey don't worry... Yes, you made a mistake. But you are human, and you are a nurse, which makes you a superhero-- and superheros 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/
    ARTPOPIST likes this.
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    this too shall pass... just remember that and I pray God gives you the peace of mind you need..
    ARTPOPIST likes this.


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