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!

[Ruby Vee, BSN]

blondy2061h said:

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.

[calivianya, BSN, RN]

VANurse2010 said:

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.

[VANurse2010]

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.

[suanna]

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 PARALYZE 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 "accidentally" 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.

[canned_bread]

The important thing is you learn, and that you feel. You do both. You have learned, and you feel sad. If you didn't care, I would be concerned. Mistakes happen, it's part of learning. Babies fall, nurses sneeze on sterile fields, and even doctors screw up med charts! You are doing your best.

What might help you with confidence is to cross-check the important IVs with other nurses to get your confidence back. Ask them to double check your calculations. ? Sometimes it's hard! I also find it helps me to be in the drug room when I do calculations before I go into the patient's room. That way a patient can't interrupt me and I don't feel under pressure! ?

[Megora]

@Sugarcoma

I realize this post is from three years ago, but I just wanted to say Thank You for taking the time to write this supportive, very objective post and for not saying, "learn from your mistake and move on". I am a new nurse still on probation and made a giant medication mistake yesterday. The patient is ok, I caught the mistake within 15 minutes of it happening, and everyone on my unit was very supportive, but that doesn't help with the suffocating feeling of putting a patient in harm's way. I am too upset to go into much detail but I gave a patient her am dose (very high) of insulin and forgot to scan the med (I had already done my 2 RN independent check and did not document that either). I work on an insanely busy post-surgical floor and had a heavy assignment with a particularly demanding patient (both in terms of care and emotionally). That patient alone took close to two hours of care in the busiest time for any nurse. As luck would have it, I called a resource nurse to give meds to the patient I had given the insulin to (not remembering the insulin was not scanned) because I was busy with the other one and pt #1 was being picked up in 30 min to be transferred to a different facility. As luck would also have it, pt #1 had issues with short-term memory. Resource nurse saw no record of the insulin administration, asked pt if they had received it, pt said no, and the nurse administered a second identical (very large dose) of both Novolog and Lantus. Pt's transport was on the floor 15 min later and I was preparing discharge papers when the nurse came and told me pt is caught up on all her meds, INCLUDING HER INSULIN! Needless to say, the patient didn't go anywhere and I monitored her very closely for the next six hours. The BG never dropped below 160, but I am terribly shaken by the experience and my neglecting/forgetting to properly administer a high-risk medication because I was so overwhelmed. I also put another nurse in a position where her actions could have led to an outcome I dare not think about due to my own mistake. I can't bear thinking about what could have happened if the second nurse hadn't come to me with her report right as the pt was getting ready to leave the floor...

'

[Whitesranch, BSN, RN]

Just own it! Tell your team in the huddle in the morning how it feels...you are human. I once had a nitro gtt going on a pt and titrated up a couple of times cause BP was low. I asked another nurse what the heck, it's not making any sense and he pointed out the nitro bag and turned the rate down. I had it in my head that I had neo gtt going. Lord have mercy!! We all learn from our mistakes. Hugs!!

[litbitblack, ASN, RN]

When I was new and before I fully understood heparin gtts I had a patient on a gtt with standing orders for adjustments based on ptt results. She received the entire bag-250cc- of heparin in an hour. Luckily she was fine but I felt so inadequate as a nurse. you are not perfect. It's not if you make a med error its when. And the nurses who are judgemental on med errors need to jump on another boat because they obviously think they are perfect

[Orion81RN]

morte said:

This isn't making mathematical sense. if only 75 ml had infused over 3 hours the rate would have been set at 25, not one hundred.

I was thinking the same thing.

[HannahMarine30]

I can relate to your panic. I (also a relatively new RN) administered an ordered potassium replacement an hour and a half late. As a cardiac ICU nurse, I knew the importance of electrolyte maintenance, especially in our types of patients. Luckily for me, and moreover for the patient, he wasn't technically a cardiac patient but overflow from the MSICU next door. The replacement protocols for him were less stringent and because of his non-cardiac related health issues, it was therefore not "as life-threatening" as it otherwise could have been.

Needless to say, I experienced the same sleepless nights you described, that sick feeling in the pit of your stomach. But I got through it, learned to be more careful and realized I was only human.

That's the key, know that you will make mistakes, know your procedures for rectifying/correcting/reporting the mistakes, and always be honest. That's all you can do. Nursing is an incredibly difficult job, give yourself some credit for taking on such an awesome challenge.

God bless!

[m1820.s]

I need help I dunno how to recover. I'm scared. I'm lost. I dunno what to do anymore. It feels like this is the end

[gemivrn, BSN, RN]

I have this experience just these last few days, the patient's INR was 2.5 (labs was drawn that day) he has a coumadin order 5mg it was scheduled to be given at 1700 and I started giving medication earlier, (1646) I double check with the day shift nurse if there is any orders that can affect my medications pass that afternoon (prior to the incident) and we didn't have any new orders, so I went ahead and gave meds to all of my 13 pts. then the doctor came 1725 and started writing an order, he asked me to hold the patient's coumadin that day, I was so nervous because I already administered the 5mg coumadin, I told the other nurse about it and asked her about the other order that says " check the PT INR before administering the coumadin" ( this order has been DC by one of our staff c/o doctor's order, it usually there to block or to remind us to check the PT INR result in anticoagulant flow sheet and it also tells us what dosage of coumadin needed to be given at certain INR result, I am a new nurse, I just want to know is there a med error in my part? the other nurse admitted that he was wrong for discontinuing the order "to check the PT inr prior to giving coumadin ". any comments will be greatly appreciated. thank you.