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

  1. 0 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???????
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  3. Visit  tinkerbell419 profile page

    About tinkerbell419

    Joined Jan '12; Posts: 120; Likes: 45.

    93 Comments so far...

  4. Visit  tinkerbell419 profile page
    0
    I did pass my placement, but at the time i felt confident enough to give those medications. Because my mentor never ever bothered to explain i didnt realise i was making an error.

    But i suppose i should have told my mentor, instead i was very frightened and scared. I was put on an action plan in my first year for something else and that scared me, so i didnt want to go through that again.

    What if my mentor tells uni what happened, would they have something to say to my mentor and tell him that it was half his fault too. I feel that he let me down in a way.
  5. Visit  Purple_Scrubs profile page
    16
    Anytime you administer a medication you alone are responsible for knowing the med, understanding what it is and how it is to be given, and checking the 5 rights. No, the mentor is not to blame.

    That said, humans make mistakes and none of us is perfect. Learn from it and be thankful that no harm came to the patient (because a med error with a wrong route can have disasterous consequences).
    symphie, brillohead, caliotter3, and 13 others like this.
  6. Visit  coco.nut profile page
    12
    I don't understand why you would give a med without knowing what it was for. If you are allowed to pass meds alone, then it is entirely your fault that this occured. Even if your instructor was present it does not excuse the fact that you did not know what the med was.

    Also, how did you know this med wasn't harmful when given the wrong way, especially if you did not tell your instructor? Imagine how the mother felt when you admitted you didn't know what you were giving to her child. It's a hard lesson, I'm sorry this happened.
    Btdthat08, brillohead, fiveofpeep, and 9 others like this.
  7. Visit  tinkerbell419 profile page
    0
    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.
  8. Visit  Purple_Scrubs profile page
    28
    I seriously question your judgment if you identified a medication by color alone. Did you not even look at the label? Correct med administration is first semester stuff. If you were in the program I graduated from, you'd be out.
    brillohead, caliotter3, fiveofpeep, and 25 others like this.
  9. Visit  tinkerbell419 profile page
    0
    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.
  10. Visit  tinkerbell419 profile page
    0
    I knew what the medicine was but i thought it was administered by ng tube.
  11. Visit  tinkerbell419 profile page
    0
    Like i said, i had a discussion about it with my mentor, he asked why i didnt say anything and i explained the i was worried about what happened. He said that he wouldnt have shouted at me. He said that in future, i should really wait for the mentor to be present when administering the medications.
  12. Visit  mazy profile page
    16
    I agree that anyone can make a med error, it happens to the best of us. However, the process for handling a med error is to assume full responsibility for it, figure out how it happened, what the thinking was that caused it to happen and then use that as a learning tool not to make a med error again.

    It is your responsibility to know your meds. To know what med you are giving, what it is for, and how it needs to be administered. You will find that there are many meds that look alike, or sound alike, or the same med that comes in different doses, or the same med given by different routes.

    Before you give that med you have to be very, very clear about what you are giving.

    So. In answer to your question. Yes. You are fully responsible for this.

    Also, a med for oral thrush is given by mouth so that it is absorbed into the membranes of mouth. It does not act by being given into the stomach.
  13. Visit  mangopeach profile page
    6
    To answer your original question. No I don't think the mentor is to blame.
    donsterRN, wooh, not.done.yet, and 3 others like this.
  14. Visit  dudette10 profile page
    2
    Quote from mangopeach
    To answer your original question. No I don't think the mentor is to blame.
    Agreed.

    To the OP: Did you not have a medication administration record (MAR) available to you prior to administering meds? If you did, why didn't you check it prior to admin'ing the meds? If you didn't, why not?
    nicenurselpn and tvccrn like this.
  15. Visit  Esme12 profile page
    15
    Quote from 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???????
    i feel like i'm being punked.....but if you are serious, you need to be very concerned.

    any nurse is responsible for the meds she gives. any nurse before she gives a med needs to know what the med is, what the med is for, how the med works, what side effects are possible, what the dosage is and by what route the med is to be given. there are many "look alike", "sound alike" meds that if confused have fatal consequences. this is particular a potential in the pediatric population. your mentor's only mistake was trusting you to do the right thing. then when the mom saw what you were doing you actually admitted you had no idea what the drug was for but it's not a big deal?? if i was the mom you would have had some answering to do.

    while everyone makes a mistake you need to own it and begin to practice rmedication administration in a much more careful and serious......and if you do make a mistake you need to man up and admit it so if there does need to man up and admit it so if there is an intervention necessary it can be taken and potentially save a patients life

    ..http://www.sfgate.com/cgi-bin/articl...97h6.dtl&tsp=1

    http://seattletimes.nwsource.com/htm..._nurse21m.html

    how can you safeguard your practice from medication errors? for starters, be conscientious about performingfive rights" of medication administration every time--right patient (using two identifiers), right drug, right dosage, right time, and right route. some experts have expanded this list to include:
    • right reason for the drug
    • right documentation
    • right to refuse medication
    • right evaluation and monitoring.be sure to use the safety resources available at your facility. don't use workarounds to bypass safety systems. in a 2008 study, one-third of nurses reported they sometimes bypass safety systems. nurses working in critical care and pediatrics were more likely to do this; yet medication errors in these settings can be particularly devastating. where nurses routinely bypass safety systems and create work­arounds, the employer must conduct a root-cause analysis to identify the reason for the workaround, and take action to correct the situation and prevent recurrences.
      additional steps you can take to promote safe medication use include:


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