Terrible Medication error - pg.4 | allnurses

Terrible Medication error - page 4

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... Read More

  1. Visit  cheri1859 profile page
    0
    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 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 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 with hold 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
  2. Visit  PacoUSA profile page
    3
    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
    imintrouble, Chrisslr6, and CamillusRN like this.
  3. Visit  calivianya profile page
    0
    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.
  4. Visit  Chrisslr6 profile page
    0
    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.
  5. Visit  VANurse2010 profile page
    0
    Quote from calivianya
    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.
  6. Visit  Ruby Vee profile page
    0
    Quote from VANurse2010
    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.
  7. Visit  VANurse2010 profile page
    0
    Quote from Ruby Vee
    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?
  8. Visit  Ruby Vee profile page
    0
    Quote from VANurse2010
    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 occaisionally, 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.
  9. Visit  blondy2061h profile page
    0
    Our pumps go crazy beeping after 2 minutes paused. 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?
  10. Visit  Ruby Vee profile page
    0
    Quote from blondy2061h
    Our pumps go crazy beeping after 2 minutes paused. 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?
    You flush the lumen so it's not filled with blood. And the carrier behind your pressors will get things up to speed quickly.
  11. Visit  calivianya profile page
    0
    Quote from VANurse2010
    I *never* pause pressors when drawing labs. I would rethink that practice.
    I never pause if the patient has a second line or an art line. Not all of our patients get art lines, unfortunately. I think once we've hit the Epi drip stage a patient should definitely have an art line, but it doesn't always play out like that. I never draw from the line pressors are running on if I can help it.

    It's especially frustrating when all the patient has is a PICC and I know all the lumens terminate together; I feel like I have to put everything on hold for sure when it's a PICC I'm drawing from. We have a couple of intensivists who will usually order a PICC before coming to drop a central line because they like to sleep through the night, which they can do if the PICC team drops the line instead of them.
  12. Visit  VANurse2010 profile page
    0
    Quote from Ruby Vee
    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 occaisionally, 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.
    Why? Because your response didn't address the situation I had in mind.
  13. Visit  suanna profile page
    0
    The most important thing you have gained from this is the knowledge that EVERYONE makes a mistake now and then. You feel bad about it, and you move on. DON'T LET THIS PARALISE YOUR NURSING CARE. I made a med error in school, and it was serious. I was so upset by the error (and almost getting expelled) I caught myself in a half a dozen errors in the next couple of weeks. I was spending so much mental energy worrying about the error, I didn't have my mind on what I was doing right then. By the way- I can't imagine your error making that much of a difference in the K+, but I don't know the patient. If they had good enough kidney function to pee off that much K+, why were they on a drip- not just timed doses?, If they had poor kidney function, you couldn't pee down your K+ that much from the dose you described. I've given the amount you "accidently" gave by drip as a slow IV push dose, no harm. I'd bet the K+ would have been close to that no matter what you did or didn't give.The biggest fear is if you give big doses of Lasix fast- the patient goes deaf- forever. If they can still hear, it isn't too big of an issue. Learn, forgive yourself, and move on.


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