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

tinkerbell419 · Jan 28, 2012

Im sorry if ive confused people with what i have been saying, i did have the knowledge of the medication and believe that i was adminsitering the medications too quickly to get another job done which is how the mistake happened.

I was very grateful that i did pass my placement, as i worked hard overall, but unfortunately the medicine error really panicked me, and i had quite an in depth conversation with my mentor about it. He did say to me, why did you not tell me and explained the importance of speaking up, that it is hard to admit to error but you have to for sake of patient.

He also said that he should have really gone through all the medications but didnt have time to sit down with me.

In future though, im going to familiarise myself with all the medicines, their pharmocology and propeties, their side effects, route of administration and take notes. I think i should also plan what jobs needs doing in order of importance so that i have no reason to rush, and to really double check everything im doing.

I think it would help if i stopped feeling anxious and nervous of placement too.

tinkerbell419 · Jan 28, 2012

To the above poster in regards to the nystatin, it was drawn up in a really tiny purple syringe.

tinkerbell419 · Jan 28, 2012

Im not sure what else i can add to this topic, but say that i am very sorry and it is a lesson that has been learned.

I knew which medicine was to be given via ng, and which one to be given by mouth, however if can be easy to get them mixed up as they are the same colour, so you do have to be careful.

and i can only think it was an automated action that i accidentally picked up the tiny little syringe and pushed the oral candiasis medication into the ng tube by mistake, just when i finished pushing in the other one to treat gastro problems.

What upsets me is that ive given the child her meds quite a few times and did it with no problem at all, so i dont know how i managed to make the mistake, but it happened.

I have since taken on board the advice and comments that my mentor fed back to me after it happened.

He said that i am good with carrying out tasks and observations in that i get them done on time, but need to really think through tasks more and to ask more questions if unsure of any procedure, to ask more questions if uncertain of anything, and to feedback more to mentor. I have a good and caring rapport with patients and their families but the area highlighted was to plan ahead of tasks to avoid and minimise any potential mistake and to really think and be meticulous in what i do, pay more attention. I know what i need to start working on.

I said to him that im am eager to do well and so i am taking this criticism on board, as i want to do even better and get better comments. I feel that i do have the right mind set, but i think i am maybe too quick to do things and need to plan ahead, even talk to myself about what im doing and go through it in my head first.

So i need to change the way in which i work, be more thorough, organised and methodical.

Esme12, ASN, BSN, RN · Jan 28, 2012

I am not sure how they do things in your school but I have always insisted that the student nurse look up all the meds for the patients they will be giving them on BEFORE they show up for clinical. Medicines are no joke and dosage or route mistakes can cost someone their life. You need to sit down a really reflect how you need to change you practice and demeanor to prevent this from ocuring again. You need to slow down, take a deep breath and double check EVERYTHING, before someone gets hurt. The only blame I can place on your mentor was not ensuring you were safe to give meds when using his license. The rest is up to you.

You have recieved some excellent advice. Good Luck

tinkerbell419 · Jan 28, 2012

I am safe to administer meds, I had the patient for nearly every shift and done her ng feeds correctly, I would give the nystatin on the foam stick, and give her the mouth wash and give her constipation medicine.I did her meds loads of time with no error by myself. I knew what she was on, route of admin and frequency.I took my eye off the ball and I kick myself even now that I picked up the syringe and confused myself.Believe me with all the comments, I really am embarrased and angry with myself that I lost my grip for a moment and picked up the syringe, even now i think how did i manage to do that.I know I need to focus on detail, be more organised, compile a checklist, familiarise myelf with the patients drug chart and to get a good understanding of the medications each patient is on.I need to learn to avoid any distracton, and to really check everything is in order first.I am a determind person and I will do my upmost to work on this. My next placement isnt till summer and I absolutely say on my life that this won't be a repeat performance.I was really stressed as a result and angry with myself, but with all the comments and mentors fedback I know what I realy need to work on.

kids · Jan 28, 2012

The medicine was yellow, now i know the child has a yellow medication that is given via ng tube so i assumed it was that medicine, so that why i pushed it through the ng tube.
Now if it wasnt the same colour, i would have queried it.
As i have seen my mentor pushing a yellow medcine into the tube, i assumed it was the same yellow medication that is used to treat constipation but it was something else. The second yellow medicine was for oral thursh and i didnt realise.

I know the medicine isnt harmful, the child has a very teeny tiny amount in a syringe, so i knew it would not harm her, if anything it would contain a mild antiseptic, as she has it in her mouth, she is going to swallow it so it will be absorbed in her mouth when she digests it, and it will pass into her system.
As i say it was a small amount which is put on a foam stick and brushed round her mouth. To e honest i should have noticed by the quantity but didnt.

I'll be honest, I'm horrified by your posts.

You don't seem to have a grasp of the very basics of safe medication administration.

I sincerely hope the error IS reported to your school so that you can be remediated.

tinkerbell419 · Jan 28, 2012

What i have described here is what happened

I knew what medications i was handling as they were all together in a tray.

What happened is that i was pushing in the other medicine that goes in the ng tube which is for the childs constipation and cramp, and then picked up the other 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 said it is very mild stuff and wouldnt have harmed her. She has a pee sized amount in a very tiny syringe.

The problem is that as i was pushing the medicine for constipation, i automatically picked up the other syringe of nystatin medicine and pushed it through after, its only when i pushed it through that i realised my mistake.

And i think i got confused that i forgot that i had already pushed in the ng medicine for her constipation.

They fact that both medicines were the same colour and lying next to each other in a tray didnt help.

But i do know which is which, i just dont how how i managed to confused myself and forget to put it in her mouth.

NCRNMDM, ASN, RN · Jan 29, 2012

No, I think you are to blame. Before I give a medication I look it up in the computer and I make sure I know what it is, what it's for, the schedule, the dosage, and the route. If you had paid attention to the route of administration (which is one of the rights of medication administration) you would have seen that one med was PO and one was given via the NG. Your instructor should have been in there with you while you were giving these medications, and I do fault him/her for obviously not being present. Had the instructor been present, he/she should have realized your mistake and stopped you prior to you making it. However, it is not your instructor's responsibility to hold your hand and check all your information for you.

Also, once you realized that you made this error, a variance report should have been filled out, your instructor should have been notified, and the RN who actually had this patient should have been informed of exactly what happened. In most cases, the physician also needs to be informed of what has happened, and this may have been the case in this situation. You, as a nursing student, should realize that this error puts the RN in charge of the patient, you, your instructor, and the facility in danger should that mother make a fuss.

Also, telling a patient family, "I don't even know what this stuff is" is so unprofessional that it almost makes me physically ill. Anytime you are administering a medication, you should know what it's for, and other information about the drug. You don't have to know every last little detail (because that's physically impossible), but you should know side effects, adverse effects, trade name, generic name, what it is used for, and how it works in the body at the very least. If you don't know what a drug is, and you don't have time to look it up, then don't give it. It's that simple. If you have time to look it up, you should make every effort to do so. You should be especially careful when giving medications to pediatric patients (even more so than when administering medications to adults). It only takes a small error, such as giving 0.5 mg or ml (or less) too much, and you can kill a pediatric patient.

CapeCodMermaid, RN · Jan 29, 2012

I'm thinking this so called student is FOS. In one post she calls the medicine the yellow med. In another she calls it the mouth stuff and lastly she calls it nystatin.

Something smells funny in here.

kgh31386, BSN, MSN, RN · Jan 29, 2012

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

Ok....trying to keep a straight face on that one. If you see this answer on a test, don't pick it lol. I swear when I was in school we had answers like this on a test to help you narrow down the choices. Therapeutic communication...nailed it(sarcasm)

Let me bullet point my response because there's much more I'd like to say.

-You aren't safe to give meds

-Don't color code your meds. Wait til you get to that all that clear IV stuff

-Your fault

-Your fault still

-You say you don't know what this stuff is? Really now

-It confused you because it wasn't during the normal time, ok what about that STAT stuff they order all times of the day?

-If you get checked off on something, no one should hold your hand. Instructor probably checked the stuff at the door and you still gave it the wrong way

-Confused because you had an automatic reaction to just pick it up and put it in the tube...ok soooo when you have IM shots, IV pushes, etc to give at the same time(and they're all clear). You just gonna shove it all in the IV? There's your reaction again. Tell me how it turns out when you give your Heparin shot, Flu shot, and other not good stuff IV.

-You haven't learned from this

-You never elaborated on what happened with your first semester issue.

-I think we got punk'd.

kgh31386, BSN, MSN, RN · Jan 29, 2012

I'm thinking this so called student is FOS. In one post she calls the medicine the yellow med. In another she calls it the mouth stuff and lastly she calls it nystatin.
Something smells funny in here.

That dang yellow pill worked finally :bow:

donsterRN, ASN, BSN · Jan 29, 2012

Well, congratulations sweetie; you got us! Yay for you.

It should be obvious to you now that few here believe your story. If, and I mean IF, any part of this is true... you're scary and have no business being in this profession.

You need help. I hope you get it.