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???????
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
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
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:
reading back and verifying medication orders given verbally or over the phone. (see reading back medication orders by clicking on the pdf icon above.)
asking a colleague to double-check your medications when giving high-alert drugs
using an oral syringe to administer oral or ng medications
assessing patients for drug allergies before giving new medications
becoming familiar with your facility's "do not use" list of abbreviations. in 2004, the jc published a list of abbreviations that shouldn't be used because they can contribute to medication errors. for instance, in one documented case, a "naked" decimal point (one without a leading zero) led to a fatal tenfold overdose of morphine in a 9-month-old infant. the dosage was written as ".5 mg" and interpreted as "5 mg." http://www.americannursetoday.com/article.aspx?id=6356&fid=6276
Specializes in Care Coordination, MDS, med-surg, Peds.
I have so much to say, that saying nothing is probably the best thing. Unfortunately, I have seen situations where one nurse handed another a med cup and said give this to mrs jones. REALLY? Not gonna happen. I MUST know what is in the cup, what it is for and if the doseage is correct and if it is indeed for mrs Jones. I am aghast that the OP did not immediately fess up!!
Once, in the hospital during report, the off going nurse told me: I gave so and so her valium IVP. It crystallized in the tubing so I pushed it fast to get it in. I asked her, Is your pt still alive? When she looked at me in surprise I said..well, you pushed a crystallized solution directly into a vein aren't you aware of what could have happened? You are lucky she didn't die. This nurse then got a little upset.
I guess I could have been ore diplomatic... BUT, as you all know MEDICATION CAN KILL, MED ERRORS DO KILL. WE, as nurses are the last line of defense... WE MUST be aware of what we are giving, what it is for, side effects and compatability among other things.... What scared me, was that she had no idea that she could have killed that pt, so I probably was less than diplomatic, and may have taken a bite or two out of her sorry butt.
I know we all have to learn, but one thing we should learn in nursing school is how much we don't know, and how much we have to LEARN.
ok, off my soap box for now..... its just that the OP seems unaware of how serious her actions were. and that upsets me
Tinkerbell, what I find disturbing is not the fact that you made a med error -- that can, and does, happen to anyone -- but the fact that you don't seem to think it's a big deal. Also, you seem to think the following things are true: 1) Giving a medication by the wrong route isn't a problem if the amount is "teensy" -- WRONG! Some medications are very powerful even in small quantities. 2) It's ok to identify medications by color. WRONG! Do you know how many "yellow" medications there are out there, especially in peds? A lot. And the same medication may be yellow one day and colorless or pink the next -- pediatric medications often have flavored syrups added to them, and the color isn't always the same for the same med, and 3) since it's supposed to be given orally, it's not dangerous to give it by NG tube -- WRONG! It's supposed to be rubbed onto the inside of the mouth, which means most of it will NOT be swallowed.
You have a lot to learn about medication administration, and even more to learn about taking responsibility for your own mistakes. For the sake of your future patients, I hope that you learn this and learn it quickly!
I can not agree more with the other posters.. OP, please take this very serious. I am shocked at your response to this and the fact you tried to HIDE your error which is extremely dangerous to your patents.
I'm really quite shocked at your replies to everyone. If you were at my school you would have been immediately taken off the floor, failed clinical and likely removed from the program for several different reasons such as not informing the instructor immediately, giving meds w/o knowledge of them and safety checks, not being able to recognize you mistake. The last one is the biggest problem I believe, as it means you are a constant danger to patients on the floor.
The fact that you blew off the med error as no big deal and focused on your fear of getting in trouble speaks to your lack of maturity and concern for your patients. I sincerely hope your instructor watches you closely and that the school is made aware of the situation.
No blame should fall on your instructor. I agree with all the other posters. Your attitude is careless and I pray that none of my loved ones are ever at the hands of someone who shares your attitude.
I also feel like I'm being punked. While this PARTICULAR mistake is most likely not going to harm the pt, that's just luck that this was the mistake that was made. My nursing program did not allow students to give meds without an instructor or one of the nurses from the unit/floor present and supervising. This is a prime example why. Identifying the med by the fact that it was yellow??? No. Even when I am giving the exact same medication, from the same spot in the pyxis, to the same patient multiple times in a shift (sometimes upwards of 15x), I still check the packaging for drug NAME, DOSAGE, EXPIRATION DATE, and the MAR for drug NAME, DOSAGE, ROUTE, FREQUENCY, patient name/MRN and then the patient's wristband for name/MRN. I also never give anything without first knowing what it is for, how it is administered, possible side effects/adverse reactions, dosage range, and more. Please realize that while mistakes are made, there is a reason we own up to them and next time you, and your patient, might not be so lucky.
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???????
Why would you expect your mentor to "tell you which is which"? If you're administering the medications, it's YOUR job to check the MAR and the label of the medications. Your mentor probably assumed that you knew that you need to do both in order to safely administer medications. If I had to guess, the medication you're referring to would be Nystatin which is often used orally via swish/swab for oral thrush. You should have A) looked at the MAR which would have told you the route in the order and B) checked the label. It's also always a good idea in pediatrics to verify with the parents that the medications and dosages are correct because orders are sometimes wrong. And NEVER identify a medication by its color.
Now, I have mentored students and I would never allow them to give medication without my being in the room as they are not licensed to do so; however, you made the mistake and you need to take responsibility for it. Saying "well my mentor didn't catch it" is not an excuse. There's a reason why you're supposed to do safety checks.
Nurses are at the bottom of the food chain when it comes to medication administration. There is never any excuse acceptable for administering the wrong med. Or the wrong route. It is never anybodys' fault but the nurse who gives the med.
If the MD orders it wrong, the nurse has to know that.
If the pharmacy dispenses it wrong, the nurse has to know that.
If it's labeled wrong, the nurse has to know that.
It's not fair, but the person actively giving the med is responsible for everything about that med before it is given.
Esme12, ASN, BSN, RN
20,908 Posts
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:
additional steps you can take to promote safe medication use include:
http://www.americannursetoday.com/article.aspx?id=6356&fid=6276
[url=http://www.ccforpatientsafety.org/common/pdfs/fpdf/presskit/ps-solution1.pdf][/url]
http://www.ahrq.gov/qual/pips/issues.htm
http://www.chcanys.org/clientuploads/downloads/membership_articles/jcaho/jcahoproject_lookalikesoundalikemedicationsforhospitalsambulatorycare.pdf