Administered wrong antibiotic

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I just graduated this past May and I have been working at a small hospital on the med/surg floor for about 2 months. I barely got an orientation and I was put by myself way too soon. The nurse/pt ration is way too high, it can be as much as 10 to 1. Yesterday, against my better judgement, I got left in charge for a few hours because the charge nurse had to leave a few hours early. It was just me (I'm an RN), and an LPN. We had 8 pts a piece, and we were both really busy. She had 2 pts that had vancomycin due at the same time. Well, we all know that vanc is supposed to be hung on time. So she asked me if I would hang one for her. We were both running around like crazy, and she just reached into her cart and handed me the bag. I only looked at the pts name, not the drug. I know that was a huge mistake, and I always look at the drug any other time. We were just really busy, no excuse I know. Anyway, I went and hung the antibiotic. A few minutes later, the pt called to the desk and said his IV site was buring. So I went in and slowed the rate down. A few minutes later, he said he was burning and itching. So I went back in, and when I looked at the bag, I realized it was zithromax and not vanc. I immediately stopped the IV and flushed the line. I told the LPN what had happened and she called the doctor. The pt ended up being fine, just had a mild reaction, but I feel so stupid. I know I should have looked at the drug, and I am really kicking myself for it. I had to fill out an incident report on it, and I know I am going to get it bad from the DON. To make it worse, the LPN doesn't really seem to like me, and she put all the blame on me. She didn't even take any responsibilty for giving me the wrong bag. I know she is going to throw me under the bus. I even have to wonder if she did it on purpose. I just feel so stupid and embarrassed.

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carrie_c,

I'm start with telling you that it is OK. Accidents happen, really they do. You have quite the patient load and with that it was almost waiting to happen. You know where you dropped the ball and I would simply explain it the way you did here. Take responsibility, tell them you know the mistake, the patient wasn't harmed, and tell them how you plan on preventing it from happening again in the future. Just honest and truthful and you will be OK.

As much as we hope not to make med errors, they are actually quite common. There are numerous threads on this site about it happening, I've done it and I honestly believe all nurses have. Not to mention the ones that don't get reported.

Explain exactly what happened and if the LPN attempts to throw you under the bus, then she only makes herself look bad. They will expect you to be accountable because you were the one that actually hung it, and that's OK because you are already doing that. Just don't blame the LPN for it or it's passing the buck. She shouldn't have handed you that bag but she did, so it is what it is. I would explain exactly what happened, but still own it.

It is such a horrible feeling to know you messed up. Try to look at the big picture, the patient is OK. They had a mild reaction, but they are still OK. You are not stupid. You are a human being and just try to remember that. Hugs being being sent your way. It will be OK. Unfortunately, you aren't the first and you won't be last to make a mistake. We aren't perfect, we just try really hard to be.

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Thanks. I won't blame the LPN, I just think she should step up and take some of the responsibilty too, but oh well, I guess it doesn't matter. I know I'm the one who hung it and I should have payed more attention. I also didn't feel comfortable being in charge with so little experience, and I will refuse to be charge again until I get some more experience. The nurse/pt ration is so high at this hospital, I am looking for something better. I wish these hospitals would realize how dangerous this is.

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Exactly. She should take some of the responsibility. I think that if she doesn't, she will only make herself look bad. As for charge, I guess lesson learned. That is the thing with nursing, hospitals put us in situations that we aren't comfortable with and then when we make a mistake it all falls on the nurse. It's not fair at all. Chin up though. It'll work itself out. :)

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Specializes in LTC, Nursing Management, WCC.

It doesn't matter who handed you the medication. You are the one ultimately responsible as you are the one who administered it. Remember the 5 rights. Take it as a lesson learned. We make mistakes... the bigger picture is that we learn from it!! :)

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So true. I definitely learned from it.

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Yep.... you learned something that didn't hurt anybody...and made you more alert to what can happen :)

I graduated in 1985- and up to 14 patients on NIGHTS wasn't unusual....but on days or evenings, it was closer to 6-7...... You have a lot of acute patients. Not good. Yes- you hung the med- but being overwhelmed isn't helping. Hang in there- and keep your eyes open for a job that has better ratios :)

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Yep.... you learned something that didn't hurt anybody...and made you more alert to what can happen :)

I graduated in 1985- and up to 14 patients on NIGHTS wasn't unusual....but on days or evenings, it was closer to 6-7...... You have a lot of acute patients. Not good. Yes- you hung the med- but being overwhelmed isn't helping. Hang in there- and keep your eyes open for a job that has better ratios :)

The hospital I work at, the nurses at night have less patients than the nurses on days. That makes absolutely no sense to me.

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Specializes in LTC, Pediatrics, Renal Med/Surg.

Was that patient going to get zithromax at some point since the patients name was on it?

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Was that patient going to get zithromax at some point since the patients name was on it?

He had received the zithromax the night before, and it had been discontinued. So I'm not even sure why it was still in her cart.

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10 to 1 is not safe. Is there a nursing supervisor, I would call them first if anyone told me I had 10 patients.

And if it wasn't fixed, then I'd probably quit.

Aside from that, Medication errors happen sometimes. Take a breath and don't lose any more sleep over it.

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Specializes in Psych ICU, addictions.
I only looked at the pts name, not the drug. I know that was a huge mistake, and I always look at the drug any other time. We were just really busy, no excuse I know.

That sums it up. Never give a medication without checking it yourself...even when other nurses pull a med for me, I always verify what I am giving because mix-ups happen. I've had nurses get me the wrong med by mistake...and I've also grabbed the wrong med for others by mistake. We're human, we make mistakes.

Yes, it was your fault for administering the wrong medication, and you can't blame her for the error that because you didn't bother to double-check the bag. It would be nice if she had stepped up and said something like, "oh, I gave her yesterday's bag by accident" or at least have been supportive of you instead of going on the offensive. But ultimately the responsibility for the med error is yours.

Forgive yourself and learn from it. At least nothing serious came of it, and I bet you'll never forget to double-check again...if you're like I was after mine, you'll be paranoid for a long time afterwards :)

I even have to wonder if she did it on purpose.

If the LPN did hand you the wrong medicine on purpose, that's a truly frightening person that you are working with.

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