advice, please! medication error

Mulan · Oct 3, 2006

When was the insulin dc'd? If the drip was taken down and discarded when it was stopped that would have prevented this error, was it dc'd by a previous shift or on your shift?

If you know how it happened, outline what you would do differently in the future.

Thank goodness the patient is okay.

Good luck to you!

Antikigirl, ASN, RN · Oct 3, 2006

Oh dear, I just went though my first med error where I put in dilaudid into a PCA and it was set for Morphine...patient and unborn baby okay, but WOW! I felt like dirt for a day or two.

But I see mistakes as being a learning experience (so THANK YOU for posting it! I will be sure to check insulin pumps and be very clear...I don't work with those often so a point where I can also make an error!), and along the same recovery line as a loss! Let me explain...

When you make the mistake..don't we tend to go through various timelines of the following. Denial "no way...wasn't me was it?"...Anger "Man I am so mad at myself...how could I do that!!!???" Sadness "why oh why did I do that...I could have hurt someone...should I leave the profession...I feel so horrible!". Then acceptance "I made the error, now what do I do to show it was an honest mistake, learn, and help make sure it doesn't happen again!".

You seem to be at stage sad, and acceptance! Now the trick...acceptance..what to do? Think about that day and incident, I keep a journal note on these types of issues being very vague about pt info (for confidentiality), what I did, why I think I did it, what could have prevented it, and what can be done to stop it in the future (or at least help lower the risk).

Think about that for a while, and realize we all make mistakes...heck this was my first in 7 years of nursing...and it was a big blow to me emotionally. But I got back on that horse wiser and will learn and keep learning from it!

When talking to management, be firm but don't be argumentitive. Accept your error, and ask them point blank...what can I do to lower the risk of this happening for myself and others!? That shows you are responsible and proactive...and that helps so much when things are left in their court to decide! Keep a hankie ready..believe me I teared up and they saw I was fighting through the shock and sadness of my mistake...but was still proactive! :)

Good luck...and believe me you are SOOOOOOOOO not alone!

As suggestion...if a pump of any kind is NOT to be turned off or disconnected, we mark that on a piece of silk tape on the machine and the line near the hubs! Maybe that will be a suggestion that is proactive and shows you are thinking of making things right for more than yourself!

Trauma Columnist · Oct 3, 2006

How awful for you and the pt. Like you said, I would go in there with a plan of action (written down) as to how to correct this so that it doesn't recur and a sincere apology.

I would own up to it and keep your part of the discussion on target - don't offer excuses. I know this is so hard for you. Anyone who has been a nurse for any amount of time has made med errors. Take care of yourself.

RNsRWe, ASN, RN · Oct 3, 2006

I"m so sorry you're dealing with this. As for being a veteran of nursing, it reminds me of a saying a former (VERY veteran) clinical instructor used to use: "If any experienced RN tells you she's never made a med error, she's either lying or too stupid to know the difference". She never clarified HOW experienced one needed to be to expect it, but I think we got her drift.

We're human.

Bethy-lynn · Oct 3, 2006

Not too long ago, a nurse at my ho accidently hung a Nimbex bag in place of a new Neo bag. Needless to say, the pt coded, and then died about a month later (don't think he died because of the code though, actually). This nurse has been a nurse, and a very good one, for about 15 years, and this was her first major med error. The point is that everyone of us has made a med error at one point or another. this gal went in with an understanding of what went wrong, didn't deny, or try to pass blame, and came up with a plan for how to prevent this. She also did an inservice for everyone on the unit about the new policy. Perhaps you could do an inservice about the importance of taking down dc'ed med bags. It will come to you.

purplemania, BSN, RN · Oct 3, 2006

I believe insulin is responsible for more REPORTED med errors than any other drug. I feel your pain, really. Hope your facility is one that sees an experienced and repentant nurse who deserves mercy as well as justice. Perhaps you could volunteer to speak to other nurses about med errors. My best wishes to you

BSNtobe2009 · Oct 4, 2006

I've been reading as much as I can regarding med errors, and I know they happen, and I also have learned from reading these boards that all of them are taken very seriously by the hospitals.

However, keeping that in mind, do hospitals have systems in place or do they teach you during clinicals ways to double check yourself to make sure you are giving the right meds?

I saw another post from a nurse that worked a trauma unit that was fired after about 5 med errors from her first nursing job...that scares me.

I mean, you can't be a dummy and get out of nursing school and pass the state boards...so why do some nurses make many more med errors than others?

PANurseRN1 · Oct 4, 2006

Too many pts. for too few nurses, being tired because you've been mandated, inadequate/improper orientation, look-alike/sound-alike drugs, inattention to what one is doing...there are hundreds of reasons.

mcksa · Oct 4, 2006

Thank you all for the words of encouragement and understanding- truly, this isn't my first med error- just the major one- and I was planning on going in with a written plan and also an approach for myself to be an advocate for med safety and inservice -including support for other nurses going through the same thing- I do think that they will want ME to come up with the plan to prevent these type errors ;rather than asking them what they would have me do to prevent them. It's good to know there is a place like this to go and get support, advice and opinions- thanks again for the response.

Ruby Vee, BSN · Oct 4, 2006

going tomorrow to face hospital personnel due to a serious med error concerning insulin-
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. now i feel like i'm on the firing line (literally) and need any advice on how to get through this without totally falling apart or looking like i am unafffected - i know partially what is expected of me - and know they want a plan of action as far as what my follow up will be- not sure how to outline this- please- any help would be appreciated - i'm a veteran rn of 33 years and this is driving me crazy- but also feel very blessed that the pt . survived ny error

first off, let me just reiterate what you already know. everyone makes mistakes, and anyone who tells you they've never made one is either a damned liar or too dumb to notice one.

years ago, i changed the tubings on a patient with four drips. somehow, i got the lidocaine (that alone will tell you how long ago!) and heparin mixed up. the patient kept having runs of vt, so we'd bolus with lido and turn up the drip. when i left, the "lidocaine" drip was maxed out at 4 mg./minute (60cc/hour.) we were following ptts, and the next one was due at 2000 -- right after i went off shift. it came back high, so the night nurse turned off the "heparin." meanwhile, the patient continued to have vt. not to long after mike turned off the "heparin", the "lidocaine" ran dry. at that point the mistake came to light.

i was devastated. mike had written up an incident report and turned it in (as he should have!), but i'll never know whether my nm had read it or not. mike told me at 0700 report, being quick to reassure me that the patient, while a little alarmed at his cherry red urine, had suffered no damage. i immediately went to my nm and told her about the mistake. at this point, i was a mess, crying and saying over and over again "i could have killed that nice old man. i could have killed that nice old man."

on the spot, i came up with some ways to keep from making the same mistake again and apologized over and over. when i finally wound down, i asked the nm if i was fired. "no one," she said, "could ever punish you as much as you're going to punish yourself."

in contrast, a nurse who i will call debbie (her name did start with a d) walked into a room and defibrillated a wide awake patient in sinus rhythm. she mistook artifact for vf. we've all mistaken artifact for vf, and i've seen a few people even attempt to defibrillate it over the years. none of them were fired. debbie, however, rather than being apologetic, giggled and said something to the effect of "oops! silly me!" she was gone before the end of the shift.

my point is (and you knew i had one, right?!) admit your mistake. express your sorrow that it happened, your deep regret that you made the mistake, your determination to never make another one even remotely similar and a plan for preventing it. (i'm sure you've thought of several plans for preventing it. i went over and over and over it in my head, thinking "if only i'd double checked all the lines after i was finished." "if only i'd had someone double check me." "if only i hadn't been chatting with the man's partner while i was changing lines" etc. etc. etc.) your plan doesn't have to be formal or minutely detailed, but you do want to demonstrate that you've thought of some ways to prevent this mistake.

now, take several good, deep breaths and tell yourself that you won't make this same mistake again, that you're a good nurse and a good person. i wish you the very best of luck.

PANurseRN1 · Oct 4, 2006

mcksa: Your pt. didn't die. It was a serious error, yes, but it was discovered before major harm was done.

One suggestion would be to have a dedicated line and pump for insulin infusions. That may mean the pt. has to have more than one IV site, but it takes away the risk something happening such as in your case.

I agree with RNsRWe. It makes me see red when holier than thou nurses (many times new ones) post with all kinds of blame and finger wagging when a nurse posts asking for support after an error. I think to myself, "Just wait, your time will come..."

Good luck to you, and don't let this experience get inside your head. We need veterans like you! (Speaking as a fellow vet of 21y.)