Terrible Medication Error

anon456, BSN, RN · Feb 4, 2014

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 total 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 a facade that every other nurse but us is perfect. Because they have made mistakes, too, even if they don't talk about them.

Quote
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 making 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.

purple unicirn, BSN · Sep 20, 2014

I recently took a verbal order for toradol. The order was 30 mg now and then 15mg q 6 hr x3. I put it in Meditech as 30mg now and 15 mg q 2 hrs x 3. I gave the 30g and 2 doses of the 15 mg all within 8 hours. I did not catch this error. Now I am on suspension following an investigation. The patient is fine so far liver test ok. I have been a nurse for 16 years at the same company. Now I don't know what my future held. I can't sleep and don't want to move.

CapeCodMermaid, RN · Sep 20, 2014

Don't you have a double check system? We use am EMR but when one nurse enters an order, a second nurse must verify it. There are a few of us for some stupid reason who don't have to have our orders verified. I always ask someone to double check. Even the best nurses make mistakes. I hope you and your patient will be okay.

cheri1859 · Jan 24, 2015

So I'm a new nurse and still on orientation. I had a patient yesterday on a heparin drip as well as an amiodarone drip. I was so nervous about both of these meds since it was the first time I've been responsible for either. I went into the patient's room and my preceptor and I reviewed the latest PTT and following the heparin protocol figured out the bolus dosage and the increased rate. We cosigned and all was well with that. My preceptor then left me to finish up administering the patient's po meds. I re-checked orders on the screen as well as the 5 rights. Apparently, at no time did I check in with my common sense. He was due for a 9:00 am the dosage of Xarelto. I gave it to him along with a slew of other meds. Finished up with him. A little while later I went to daily rounding (in a break room with house intensivist, case managers, nurse managers, and charge rn). We discussed all of my patients. The case manager brought my pt with the Hep drip and the Xarelto and that I should clarify with the doctor which anticoagulant he would like d/c'd. I did not make the connection that I had already given it (chalk it up to a blond moment or newbie moment. I just never made the connection and have no excuse). I place multiple calls to the MD of which none were returned - I spoke with my preceptor and she agreed that we will give the oncoming night RN the report and advise her to withhold the pm dosage (which in my mind was when it was due. Coumadin is given in the pm so I figured that the Xarelto was the med of choice for bridging from Heparin). It wasn't until well after shift change (still very slow at charting) that the night nurse came to me and let me know that I

had already given the med at 9 am. I must have had the stupidest look on my face when I said "what? I did? I just don't remember - it seems like days ago when I was giving morning meds. Anyway, nothing more was said by her and I was left standing there waiting for instructions. She walked away and went on about her med pass. I was done charting so I gathered my things, clocked out and left. On my drive home I slowly started to panic (i guess shock had worn off), I probably should have stayed and written a report or talked with the charge nurse. I came home and sent emails to my nurse manager and assistant nurse manager and am waiting for a reply. I'm so new there that no one would call me to tell me if my patient's PTT went through the roof or not. The scary part is that this was a huge wake-up call. You can check the 5+ rights of med administration but you as the nurse giving the meds are still responsible for what was originally ordered. This is what went through my mind during the po med administration Xarelto for vte prophylaxis. When I ran the Heparin through my mind - Heparin for anticoagulation d/t new onset uncontrolled a fib. I didn't connect the 2. I feel so incompetent. I knew this day would come but didn't expect this awful feeling deep down in my soul. We just want to help our patients. To do the opposite is just the worst thing ever!

Thanks for reading. It helps to know there are people out there to vent to ?

Cheri

PacoUSA, BSN, RN · Jan 24, 2015

For those of you that are new nurses and are beating yourself over the head for these mistakes ... STOP! It happens and life goes on. I remember accidentally stopping both IV channels going on a patient and without checking lines I restarted the heparin at the rate the NS was going in (125ml/hr) and vice versa. This was while I was a student and fortunately the error was caught 5 minutes later. New nurses, you are expected to make mistakes, but hopefully there is a more experienced nurse to catch them right behind you!

Sent from my iPad using allnurses

calivianya, BSN, RN · Feb 6, 2015

I have made some pretty dumb errors, too... my dumbest was not to check that a drip was running after I hit run. We have some dinosaur IV pumps that have been around forever - some of them are so old and worn out that you can't push the buttons with your finger; you have to get a pen/scissors/hemostat something and really apply pressure like you are trying to break a door down. On some of them, you just have to roll the clamp and let it stop due to occlusion because the hold button is too damaged to work. Our equipment is pitiful and this sort of error is just waiting to happen again, but the pumps are only part of the problem. The other part was me not paying attention.

In this particular case, I put all my drips on hold to draw some labs, drew my labs, restarted my drips, and all but one of the drips restarted successfully, which I did not notice at the time. The other five or six drips restarted just fine... I was in a huge hurry because I had not peed all shift and had to pee so bad that I was going to pee my pants if I didn't go right then. I passed by the tube station, walked to the bathroom (right across from this patient's room), walked back to my patient's room, and his pressure was 70s/30s. The line that did not restart successfully after I hit run was the Epi drip, of all things. :eek: I was glad I had just peed because I would have peed my pants otherwise!

Felt like an idiot, but the patient's pressure was back to at least 100s/70s within about 30 seconds, so it was no harm no foul in the end. You bet I sit there and WATCH that first drip fall after I hit run to make sure my IV pump actually registered that I pushed a button now. I am quite sure my coworkers would have stepped in if the patient had alarmed any longer than a few seconds (I was only gone from the room for two minutes, tops), but I am also glad I caught it myself instead of having someone else catch that error for me. That one would have been hard to live down.

Chrisslr6 · Apr 6, 2015

I actually had a Big mistake like this happen to me yesterday. I am a new nurse , 2months and you're description was EXACTLY how I am feeling. I feel soooo bad and Idk if I can face everyone tomorrow. The patient is OK, just to monitor q shift x 72h, but I feel so stupid... How did you deal afterwards?

Signed stressed to the MAX new nurse.

VANurse2010 · Apr 25, 2015

calivianya said:
I have made some pretty dumb errors, too... my dumbest was not to check that a drip was running after I hit run. We have some dinosaur IV pumps that have been around forever - some of them are so old and worn out that you can't push the buttons with your finger; you have to get a pen/scissors/hemostat something and really apply pressure like you are trying to break a door down. On some of them, you just have to roll the clamp and let it stop due to occlusion because the hold button is too damaged to work. Our equipment is pitiful and this sort of error is just waiting to happen again, but the pumps are only part of the problem. The other part was me not paying attention.
In this particular case, I put all my drips on hold to draw some labs, drew my labs, restarted my drips, and all but one of the drips restarted successfully, which I did not notice at the time. The other five or six drips restarted just fine... I was in a huge hurry because I had not peed all shift and had to pee so bad that I was going to pee my pants if I didn't go right then. I passed by the tube station, walked to the bathroom (right across from this patient's room), walked back to my patient's room, and his pressure was 70s/30s. The line that did not restart successfully after I hit run was the Epi drip, of all things. I was glad I had just peed because I would have peed my pants otherwise!
Felt like an idiot, but the patient's pressure was back to at least 100s/70s within about 30 seconds, so it was no harm no foul in the end. You bet I sit there and WATCH that first drip fall after I hit run to make sure my IV pump actually registered that I pushed a button now. I am quite sure my coworkers would have stepped in if the patient had alarmed any longer than a few seconds (I was only gone from the room for two minutes, tops), but I am also glad I caught it myself instead of having someone else catch that error for me. That one would have been hard to live down.

I *never* pause pressors when drawing labs. I would rethink that practice.

Ruby Vee, BSN · Apr 25, 2015

I *never* pause pressors when drawing labs. I would rethink that practice.

You'd pause pressors if you only had one line and for some reason weren't able to draw peripherally.

VANurse2010 · Apr 25, 2015

Ruby Vee said:
You'd pause pressors if you only had one line and for some reason weren't able to draw peripherally.

That's true, but I've fortunately never been in that situation. But let's say you have a triple lumen or an A-line to draw from, would you still think it's OK to pause them?

Ruby Vee, BSN · Apr 26, 2015

VANurse2010 said:
That's true, but I've fortunately never been in that situation. But let's say you have a triple lumen or an A-line to draw from, would you still think it's OK to pause them?

Why are you even asking this? You said you'd *NEVER* pause pressors. In my four decades, I've seen a situation or two where pressors were paused of necessity. Maybe someday you will be in that position. Nor did I say I thought it was "OK" to pause them. I am saying that occasionally, it has been necessary. Not desirable, not "OK" but the lessor of the available evils.

No, I wouldn't pause pressors if I had a triple lumen, a Swan, a second line, an arterial line or was able to draw peripherally.

blondy2061h, MSN, RN · Apr 26, 2015

Our pumps go crazy beeping after 2 minutes pause. If you're drawing blood out of the lumen your pressors are running on, how do you compensate for the lumen now being filled with blood or saline until that pressor can get back to the heart level?