Anyone not making med errors?

ann945n, RN · Jul 20, 2007

Med errors are part of being human. No nurse is perfect and we all make mistakes. Whats important is to practice nursing safely to minimize this risk and when one does happen to report it promptly and take actions to ensure pt safety and learn from that mistake. I truely believe until you make a med error you really dont know how to prevent them

granite109 · Jul 20, 2007

Anyone who says he/she hasn't made an error is either a liar or didn't know he/she did so. The latter is much scarier. It's important to recognize the potential severity of a med error, but not to the point that you are so scared that you over analyze and make even more mistakes. My advice would be to utilize your facilities procedures that are in place and then add your own triple check for yourself. Unfortunately, we all get into the habit of recognizing things by sight and then wonder, "did I really read that, or just recognize it?" I have worked in the ED for 7 years, and we don't have cardexes or MARs. I got into the habit of taking the meds out of the Pyxis and carrying them over to the chart and placing them on the written order. It added a step, but reminded me to read the label instead of simple recognition. While a near miss shouldn't be taken lightly; it's not a reason to beat yourself. It is a great opportunity to create your own style, safety checks and build confidence. good luck!

fleur-de-lis, BSN, RN · Jul 20, 2007

Thank you for the responses so far. This is the same thing many other nurses have told me as well. My near miss was in drawing up IV push ativan. The ordered dose came up to 1mL but I draw out all 2mLs that were in the vial. Preceptor asked me what the dose was and I immediately knew what I had done. I was horrified and really shaken up about it, but she was wonderfully supportive. I know I was a little "off" all day with a killer headache, but that is absolutely no excuse. I knew what the dose was, I just was not paying close enough attention. It is back to the 5 rights for me! Even though I know that in all likelyhood I will make med errors over the course of my career, I want to do everything I can to minimize them and prevent harm to the pts.

TheCommuter, BSN, RN · Jul 20, 2007

I knowingly committed a med error, because I did not administer a p.o. dose of MS Contin since it was not available. Not only did I make this med error with complete awareness, I also wrote it up and placed it in my nurse manager's box. There are other med errors that I have made but, thankfully, they were minor. We are all human, and we become fatigued, overwhelmed, stressed, distracted, overworked, and flustered. These things get in the way of perfection because they are integral aspects of humanness...

ptadvocate81 · Jul 20, 2007

Granite109- I agree completely. If someone says that they have never made a med error, they are lying or just didn't know. We are human and even with the technology at the hospital where I work, mistakes can still happen. Just do all you can to minimize mistakes and act quickly when/if one occurs to reduce harm to your pt. Don't freak out, but allow this near miss to keep you on your toes. Best wishes! It will be okay.

Jo Dirt · Jul 20, 2007

As a human you will make mistakes. Even seasoned nurses make mistakes. We will make mistakes and never realize we made the mistake. Anyone who tries to say they have never made a med error is telling you a big story (I do know of some nurses who would swear they never made any kind of mistake in their nursing career).

As a matter of fact, here is a hum dinger on my part. I had a patient complaining of chest pains so I pulled out the Nitroquick. This doesn't excuse me being a big dummy but it was very hectic that evening. So, I hand her the first one with a cup of water and tell her to swallow it. She looks at it then at me and says, are you sure I swallow this?

Yea, go ahead and swallow it. We'll see how you feel in 5 minutes.

So she shrugs and swallows it.

5 minutes later she says she still has the chest pains. So, I give her another one to swallow.

5 minutes later she says she still feels the same.

Well, here is the last one you can have before I need to call the doctor...5 minutes later she says she still feels the same.

So, I call the doctor, who happens to be in the ER that night.

He tells me her name doesn't ring a bell, asks what she looks like.

Well, she's old with wrinkles and gray hair.

He says (quote) That don't help me none.

She rides around in a wheelchair, too........

As he is trying to figure out who she is she rolls up and tells me she must have just had gas because it was like this big bubble came up and she feels a lot better now. So the doctor says that's good because they were lined up wall to wall at the ER anyway.

Then I looked down at the MAR and realized it was SL....talk about beam me up Scotty.

gonzo1, ASN, RN · Jul 20, 2007

I've made a few, thankfully small ones. I try to be very careful. I look at the order get the med and double check the order again. The other day I gave morphine instead of dilauded. I always tell the doctor and supervisor right away. One way to help decrease errors is to follow the 5 rights and double check orders before giving, and remember the little things like question the order if anything is more than 2, like more than 2 pills, more than 2 vials etc. Doesn't hurt to double check with other nurses too sometimes.

I work in the ER and if I am giving a med for the first time I check the drug book, call pharmacy, check with my doc or supervisor or another nurse that has the same work ethics that I do. All these things work to decrease errors.

Also I have found that I can not work more than 12 hours and deliver meds safely, can not work if I am sick or if there is something really big going on in the family like a death etc.

I was called at work and told my father in law had passed and stayed at work. It was difficult to work with that on my mind. Next time I would ask to leave or go to triage where I wouldn't be giving meds.

Dixielee, BSN, RN · Jul 20, 2007

I will just echo what others have said....anyone who says they have not made an error is not being truthful. We all make them, the key is to learn from them.

I also work ER, and we usually give the same old meds, and you even know which pocket in the Pyxix they are in, but don't let that lull you into a level of complacency. The pharmacy has been known to stock the wrong drug in the pocket. That is especially a problem when the vials look alike. 2 recent examples were lactulose in the viscous lidocaine pocket, and scopolamine in the phenergan slot.

I also usually put the meds on the chart and take them into the room with me, especially if there is more than one med ordered. Our docs like to order a multi drug headache cocktail and there can be quite a variety in the dosages, so just be careful.

There is nothing you do that is more important than giving drugs safely, so if your time is short....cut corners somewhere else, but not with drug administration.

EmmaG, RN · Jul 20, 2007

Anyone who says he/she hasn't made an error is either a liar or didn't know he/she did so. The latter is much scarier.

I agree... everyone has made med errors. I disagree with what's scarier, though. Someone who lies, doesn't acknowledge and/or tries to cover up a mistake is far more dangerous.

confused101 · Jul 20, 2007

When I was in orientation I hung the wrong fluids on a pt for 5 minutes. I had two pt.'s both in b beds that had these outragous fluid orders. It was like alphabet soup. Anyways, I was at A bed when I reliezed what I did and corrected it. I told my preceptor and he said we all do stuff like that sometimes. I have never done that again. We have computer medication administration. It helps with being safe. I can scan the pt. and then look at the order in front of me. It really helps when you are tired or someone looks the same as the guy next door with the simular name. This hospital doesn't have the fluids you have to scan though. Keep on trucking and it all will come out in the wash.

EmmaG, RN · Jul 20, 2007

We have computer medication administration. It helps with being safe. I can scan the pt. and then look at the order in front of me. It really helps when you are tired or someone looks the same as the guy next door with the simular name.

Are you talking about EMar? Where you scan the barcodes on the meds and the patient armband?

Don't allow that system to make you too comfortable. It's not foolproof, ya know. I've had patients with incorrect armbands, I've had meds that were packaged incorrectly.

And then there was an incident where a patient was given a bolus of 25,000 units of IV Heparin over an hour because the pharmacy had labeled the premix heparin bag as "Flagyl". The bags were of similar size and shape and both have red-lettering. The nurse scanned the bag and the patient and as far as the EMar was concerned, everything was correct. The label covered most of the front of the bag, but if turned over it clearly said "Heparin". How many times do we look at the back of an IV bag?

That alone was bad enough, but the patient was post chemo and pancytopenic, including a platelet count of less than 20,000.

Not trying to scare you, but be careful putting too much faith in the computer MAR.