Am i fully to blame for this or did my mentor act complacement.

[tinkerbell419]

I would be so grateful for anyone who answers this, because making me very stressed.

On my last placement in a childrens hospital, i made a medication error.

The child takes two meds both of which are the same colour. However one of them is actually for oral thrush and is to be given into the mouth on a foam stick. The other is by NG tube.

Now my mentor never bothered to tell me which one is which. In fact i didnt even know until i made the error, which i think is quite bad. Ive onyl ever seen the child have the ng tube medication, i didnt even know she had one which went in her mouth.

Anyway, i was pushin the oral thursh medication down the ng tube and her mom looked up at me and said "hang on a minute, that doesnt go down her tube, its for her mouth"

I stood there and said "oh no!, your got to be kidding me, im sorry i didnt even know what this stuff is, however its only for mouth thrush, it wont hurt her and it will just pass out of her, and she is due more later. I didnt tell my emtnor, i was frightened to death.

My mentor found out and was questioning me, i said im sorry i should have told you, but i was frightened, i dont want to be chucked off the course.

I now realise i must get over my fears and tell my mentor no matter what. I have learnt from what happened, and next time im only giving meds in the presence of another nurse.

But do you think my mentor is to blame in some respect???????

[nursecat64]

In my school, before we gave ANY med, we had to research it, and after we got it out (with supervision) we had to explain to the instructor what it was for and recite the 5 rights. We NEVER gave meds until the RN or instructor had verified that we knew what we were doing. Especially important in peds. Patient safety is first, I would question a students ability to be a nurse who worries about herself first and her patient second. I also can't imagine saying to a parent "I didn't even know what it is":eek::eek:

[DixieRedHead, ASN, RN]

The mistake that YOU made is exactly the same as if you have given the medication rectally. You gave it by the wrong route. Were I the mother, you would no longer be giving medications to my child, ever.

And not another word about your 'mentor'.

[tinkerbell419]

Im not trying to pin all the blame on my mentor.

I know it was me that made the mistake, and i admit that because i decided to give the meds, therefore its my error. However, i do feel that my mentor should have gone through with me the medications that all of our patients were on at the very beginning.

Usually i give the meds during drug round, which makes sense really because i am there when they are drawn up so i know exactly the purpose of the med and the route.

What i will say though is that i should have spoken up, i should have got over my fear really that i made the mistake.

I have administered medications before by several routes successfully because previous mentors have gone through with me all the meds the patients are on, so i know what they all are. I usually administer drugs during the drug round, which makes it easier as i get the meds out and draw them up.

The mistake is that it wasnt during drug round so i ended up confusing the medication.

I have learnt from this, and spoken to the mentor about it. I now know that i need to be very thorough with absolutely everything, and to check, double check and triple check if i have to, to avoid the slightest error or confusion.

I think my problem is that i am too quick with doing tasks, i rush too quickly to get things done as i dont want to be accused of not doing anything, however when you act too quick that causes errors to be made or accidental mistakes.

I still find placements difficult in the sense that i am being assessed and do feel under pressure with it all.

Im not excusing the mistake that i made. It happened and im angry with myself that it happened when i know that ive administered medications before.

What happened has really made me wake up and realise exactly how thorough you have to be with everything that you do.

And next time, im going to have double check everything, for my own piece of mind and that of the patient.

I do want to be a nurse and i know i can do this, if i just slowed down and think through things more. I know exactly what i need to work on, and i shall be working on this when i go back out on to placement. I am angry with myself that it happened, i cant go back in time, but next time if anything goes wrong, i will immediately run to anyone.

As ive said, i know that i can be a good student and my mentor made me very aware that i need to plan ahead of tasks, to think more thoroughly about what im doing, go through it one stage at a time to avoid any errors and mistakes, to get over my fears and nervousness.

I still have another year and a half to go- I know what i need to do, what i need to work on and im determined that i shall never make another mistake ever.

[tinkerbell419]

I am very sorry to anyone on here, and i accept the blame for what happened. I have another year and a half to go and i want to do well, i now know that i need to be much more vigilant in clinical practice. I know how easy it it to forget the check something because your rushing around trying to see to other patients.

Yes, what happened did make me feel guilty and worried. I am still in contact with the child and her mother, i apologized to the mother for my confusion and i said to her that i just dont know how i managed to get confused. I also said to her, im sorry i got confused, as you know ive given your child the same meds over and over again, so i dont know what happened on this occasion.

I know i wasnt vigilant when i made the mistake and i can only apologize. Ive worked hard to get to where i am, and i am fully determined that i will not repeat a mistake ever again and that if i do, to get any nurse immediately to recover the error, and to put fear and worry to one side.

I am a determined person and i will get there in the end. Im very sorry. x

[Ruby Vee, BSN]

although you say you're not trying to blame your mentor for this mistake, not only the title of your thread but even your most recent post are passing the blame off on the mentor. ("however i do feel the mentor should have gone through with me the medications our patients were on at the very beginning.") did you ask him to?

your learning is your responsibility. no one is going to take you by the hand and lead you through everything you need to learn. nor should they. you should be going through the medications at the beginning of the shift and asking about any unfamiliar meds -- after you've looked them up for yourself. you should be informing the mentor if you feel uncomfortable with certain meds, tasks or procedures. and if the only way you know what the meds are for, etc. is to "be there when they are drawn up," you're missing the boat somewhere.

i'm very concerned about you as a student. even after four pages of this thread, you're still refusing to accept sole responsibility for your screw-up and pointing out that "the mentor should have". you're not taking responsibility for your own learning . . . rather than say you need to look things up, you're saying the mentor should go over things with you. and when you made a mistake, your first impulse was to cover it up because you might get into trouble. would have really gotten you into trouble if something untoward had happened to the patient because of your error, huh?

ideally, you should have been dismissed from your program. you haven't been, so i hope you learn something from this -- and what you learn shouldn't be "not to make another mistake. ever." everyone makes mistakes. what matters the most is that you have a plan in place to minimize the chances of making mistakes. and what you do after you've made one. that would be to immediately own up to the mistake, confess it to your mentor, the physician, your manager and immediately set out to mitigate the potential harm to the patient. the potential harm to your patient seems to have been rather far down your list.

honesty and integrity don't seem to come naturally to you. i suggest you really, really need to work on those.

[CapeCodMermaid, RN]

I am in my last semester in my BSN program and would be horrified to even think of passing a med without personally knowing what it is and then verifying it."

I've been an RN since 1982 and I would be horrified to even think of passing a med without personally knowing what it is and then verifying it. People die from med errors. I never administer any medication unless I have poured it and know exactly why I'm giving it. I think tinkerbell419 needs to go back to Neverland--no disrespect intended but there seems to be a lack of true understanding and a whole pile of excuses about this error.

[tinkerbell419]

How am i making excuses? Ive given the child the same medication time and time again, and i know what it was the confused me. Thats all im saying, im not using it as an excuse.

I didnt carry out the checks properly, i lapsed in my concentration and so im to blame.

I know that i should have asked my mentor the relevant questions, i should have asked him to go through the medications and that i should have been more vigilant when adminstering the medication.

Im not an idiot, i dont know how i managed to make the mistake BUT from now on i know what i need to do.

I know that i cant completely avoid mistakes, but next time i will own up and speak out, putting my anxietes to one side.

I know how to give medications and ive done it time and time again.

I am sorry that i did not tell my mentor, i apologized to him for that and ive told him that i know what i need to do for the future.

I am a honest person, and it was anxiety that stopped me from speaking up. I know that sound stupid but i now know what i need to do to minimise another mistake. I know that mistakes cant always be prevented but i will raise the alarm if anything happens again.

[tinkerbell419]

I am sorry for my post and i do not mean any disrespect to anyone.

I have thought about my actions and im very sorry that the mistake happened.

I should have spoken to my mentor.

I realise now that my mentor isnt going to explain everything, this si something i need to be aware of, and i need to be on top of that. I need to take responsibility which i didnt do.

Ive learnt a hard lesson from this, and i do not want to loose my place on the course. I have worked hard to get this far.

I am genuinely upset by what happened, and i will do everything i can to minimise further mistakes.

Thankyou.

[DreaRNstudent]

As a nursing student myself I was a bit taken aback by your post. Passing meds is a huge responsibility. In nursing school it is beaten into our heads all of the rights of med administration, you know, right patient, right drug, right ROUTE, right dose, right time and to never pass a med that you don't know what its for. I completely understand that you are still learning and obviously accidents can happen. But you must be vigilant about being the best nurse possible. Even if it means admitting you made a mistake. We are always told that we must admit any med error, no matter what. Its about taking responsibility for your own actions. That is a quality that a nurse must possess, the ability to admit mistakes. It concerns me that you 1) immediately told the mother it would be fine and the med would pass right through, when you didn't even know what you were administering in the first place and 2) that you were "frightened" to admit your mistake. All I can say is that you should thank your lucky stars that the patient wasn't harmed and take it as a lesson going forward........next time you might not be so lucky.

[tinkerbell419]

I do feel very bad about what happened and wanted to discuss it on here.

You have all made me realise that i did make a mistake, one that could have been serious.

I wasnt trying to blame my mentor, i admit that this is my fault and mine alone, i just felt that maybe my mentor should have been there when i adminsitered the medications but i understand that they cant always be there, and sometimes you have to do it yourself and take responsibility for what you are doing.

I have learnt a valuable lesson, and under no terms do i wish to repeat what has happened.

If i do find myself in the same situation, i need the report the incident no matter what as students are liable for their actions.

I endeavour to do better and to really be more vigilant and careful with everything that i do, to put the safety of all patients first and to raise the alarm should anything happen again.

My mentor has made me realise the seriosuness of what could have happened, and ive explained to him that i now realise that if i do a task independantly, then i am responsible and liable for any errors, and that above everything else, to raise the alarm if anything does happen and not to be afraid of making a mistake.

We all make mistakes, but next time i need to get over any fear and raise the alarm for the sake of my patient. I do genuinely care about all my patients, and if anything else happens, i will raise the alarm.

I have made a plan of how to minimise and avoid mistakes, which is to think more carefully when carrying out tasks, to be more thorough and vigilant, and to be responsible for my own actions, to raise the alrm if a mistake is made, and to make sure there are no gaps in my learning.

I do not wish to loose my place on the course, because apart from the mistake i do care about my patients and i am very good with other tasks.

[singinRNwannabe]

See the thing is, he is a student and therefore is practicing under his instructor's RN license. The RN and hospital would've been help accountable for any adverse events.

[tinkerbell419]

Just to clarify i did know what the medication was, but pushed it through by accident.

What happened is that i was pushing in the other medicine that goes in the ng tube which is yellow and for the childs constipation and cramp, and then picked up the other yellow one (the tiny little syringe with the mouth stuff in it) in my hand, and because i wasnt thinking i accidentally put it into the ng tube too, like an automated action. Now i dont know how it happened, but i realised the error as soon as i flushed her off with water.

But i am aware of the medicine in itself, and my mentor did say that its no bigger than a blob, it is very mild stuff and wouldnt have harmed her.

However having said that, i should have spoken up. My fear and anxiety got in the way.

But ive realised that even in paediatrics, some medicines are very strong. The oral thursh stuff they use on the ward is very mild and the kids only have a teeny tiny amount to be wiped round their mouths. But ive seen and heard of stronger medications which can have strong effects.

Im still embarrased as to why i picked up the oral thrush medicine and pushed it into the ng tube, must have been an automated action where i didnt think as to what i had in my hand.

I am so glad it wasnt anything else. It has made me realise that i havent been as vigilant and on the mark as i should have been. Now i realise how easy it is to make mistakes when you get too used to a routine of doing something or through distraction.

I now have my own copy of the BNF, so next time i will read up on medicines given on the ward just so i know what meds im working with, and their normal route of administration. That way im taking responsibility for my own learning.