Terrible Medication error - page 4

by rekea526

34,036 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


  1. 1
    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 likes this.
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    Whoops! Accidentally posted twice, so look at the next post for my experience.
    Last edit by ARTPOPIST on Feb 3 : Reason: Accidentally posted twice
  3. 0
    I was thinking about starting a new topic, but then I saw this thread! It's been awhile 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 well 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 on January 2014 (last month), and have been on my own since about 2 weeks ago at a long term care facility. 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. 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 like 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!
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    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 likes this.
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    Quote from 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!!!
    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 patients 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.
    Last edit by ARTPOPIST on Feb 3 : Reason: Added more details
    BuckyBadgerRN likes this.
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    Quote from 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?
    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?
  7. 0
    When I was new I made a big mistake, too. The nurse who was double-checking me also calculated wrong so it was both of us together (even scarier, right?). And we were rushed, there was a trauma being worked on and everyone was over there helping except me and this other nurse. My patient was fine after the error but required an antidote and close monitoring, and we had to tell the family what happened. I wanted to just quit nursing right then and there and never come back. So I can relate to your post. I think a lot of us can. I confided in another nurse about it after I had the talk with the manager (and was told I was still a good nurse, but needed to go over things again and figure out what happened). The other nurse I talked to said she made the exact same mistake with the same drug! And she knew of several others who had, too. So I then went to my manager and told her, and wrote a long email with my concerns about a possible change in how that drug was given. I took totally responsibility for my error but wanted to prevent others from happening. Long story short, pharmacy made a change so that now that med is drawn out in pharmacy and not by nurses, according to the patient's order. We still have to double check it, but having an extra set of eyes in pharmacy reduces the chances of that error happening. And as upset and ashamed as I was at the time, I continue to tell my story to new nurses, as well as my good catches. Because we need to have a culture of learning from the mistakes of others instead of facade that every other nurse but us is perfect. Because they have made mistakes, too, even if they don't talk about them.


    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.
    And this is so true!! As I stated in another thread, when someone said that being late was a med error, when I was saying that I'd rather be late than make a med error. There are different kinds of errors. Being late because you were being careful about what you are given is a much easier thing to explain than giving the wrong dose or giving it to the wrong patient, etc. I do take the time to look up stuff, and double and even triple check the highest risk meds. And if that makes me late, well so be it. By late I don't mean hours. I just mean maybe not exactly within that 30 minute window of time.

    The other new nurse mistake I made involved rushing also. The tube system was down and a nurse was going to walk all the labs down herself. Well I was taking longer because I was new, and I got the lab, checked the label against the patient and the computer, etc. And this nurse is tapping her foot and looking at her watch and waiting for me to finish. I put the vacutainer in the bag but forgot to attach the patient label to it. I had the label in the bag but that doesn't count of course. So I had to explain that one, too, and what I learned was *slow down* and think about what you are doing even if you feel a lot of pressure on you.

    I am a preceptor and I have caught a couple of med errors on my new nurses. They are usually rushing or they feel self conscious with me watching them. One was just overly confident in herself. I tell them my horror story and they usually slow down after that and pay attention to what they are doing.
    Last edit by anon456 on Feb 4 : Reason: adding more


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