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Anyone Who Says They Don't is Lying: Medication Error

Medications Article   (113,329 Views 121 Replies 1,151 Words)
by BonnieSc BonnieSc (Member)

2 Articles; 25,837 Visitors; 776 Posts

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I made my first medication error as a student. I thought it would be my last, but real-world nursing was a wakeup call. You are reading page 5 of Anyone Who Says They Don't is Lying: Medication Error. If you want to start from the beginning Go to First Page.

NurseGirl525 is a ASN, RN and specializes in ICU.

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I didn't say doing documentation isn't important--I said I don't think it should be one of the five rights, or rather six rights, or fourteen rights. Documentation is important in all aspects of nursing care, not just medication, and as a previous poster said, the more the nurse is expected to do/remember, the less likely she is to do it.

I don't think any of the posters who have pointed out that most med errors don't harm the patient are trying to say it isn't a big deal, just point out that it shouldn't be a fireable offense (most of the time). If an error hasn't harmed the patient, it's only by chance/luck. My own error was comparatively tiny (giving a dose that was slightly less than what was prescribed, and which the patient had been receiving for several days), but that doesn't matter in one sense--since I didn't recheck the dose, it COULD have been a major discrepancy, I wouldn't have known.

I'd say that I'm very conscientious, and probably most of the nurses here are. Being a nurse is difficult. If I understand your post correctly, you're still a student or have just finished school. I know this is a cliche, but it just doesn't compare. Seven patients to pass meds on, with the phone ringing all the time, everyone demanding your attention, new orders coming in all the time, and that's just an ordinary day with no emergency--medication errors are an expected part of being a nurse. In fact, if a unit reports no medication errors in a month, they generally don't get praise; they get criticized for not reporting medication errors.

Luckily for all of us, there are more and more changes to prevent medication errors. But it does always come down to the nurse who hands over the pill, in the end.

That was kind of my point. I know when I'm in the real nursing world, it will be much different. That is why I pointed out I was only passing meds on a couple of patients. My clinical instructor had more students than just me, so she had to go back and forth. And I was not allowed to do anything pretty much without her. The only things I could do without her present were vital signs, assessments, and glucometer checks. The nurses on the medsurg floor I was on had about 5 patients a piece.

I just feel like in your statements you are downplaying med errors and you pretty much stated that students are flippant about the 6 rights of medication administration which is absolutely not true. It is drilled into our heads as it should be. A med error is a med error whether it hurt the patient or not. There is no such thing as a little med error. When someone says, Well it didn't hurt the patient, they need to realize they were just lucky this time. You may not be on the next one.

I also don't think it should be a fireable offense. Firing someone over a med error makes the nurses not report them. They get scared for their job and then really shady stuff will happen when the nurse tries to cover up the error that they made so they don't lose their job. Someone who is normally a great nurse with integrity, will turn and do things they wouldn't normally do so they are not out of a job.

There is always something to learn from mistakes. When a nurse makes a med error it needs to be a learning experience instead of worrying about disciplinary action. The nurse should feel comfortable to report the error to the charge nurse and the charge nurse should go over why the error was made and what to do next time so it doesn't happen again. There is always room for improvement and nurses can always learn. That is what it should be about. But, just the same, it should not ever be taken lightly.

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icuRNmaggie has 24 years experience and specializes in MICU, SICU, CICU.

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This comment relates to med errors and the other thread about skipping basic assessments. I responded to a code blue for a pt post a routine surgery with a PCA. The nurse was extremely busy and admitted to not checking the PCA at the start of her shift. The pt had received ten times the dose of the analgesic prescribed and did not survive. I was with the physician, because he wanted me to be there when the spouse came back and was told what had happened. The nurse lost her license.

The subject of medication errors should never be taken lightly.

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1 Follower; 31,842 Visitors; 1,756 Posts

This comment relates to med errors and the other thread about skipping basic assessments. I responded to a code blue for a pt post a routine surgery with a PCA. The nurse was extremely busy and admitted to not checking the PCA at the start of her shift. The pt had received ten times the dose of the analgesic prescribed and did not survive. I was with the physician, because he wanted me to be there when the spouse came back and was told what had happened. The nurse lost her license.

The subject of medication errors should never be taken lightly.

A friend who stayed by his wife's bedside when she was hospitalized told us that he was unable to awaken his wife, and immediately called for the nurse. He said she had a PCA and was receiving morphine. The nurse rushed in and found the pump settings were incorrect. Fortunately his wife survived.

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Tex. specializes in Critical Care.

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This comment relates to med errors and the other thread about skipping basic assessments. I responded to a code blue for a pt post a routine surgery with a PCA. The nurse was extremely busy and admitted to not checking the PCA at the start of her shift. The pt had received ten times the dose of the analgesic prescribed and did not survive. I was with the physician, because he wanted me to be there when the spouse came back and was told what had happened. The nurse lost her license.

The subject of medication errors should never be taken lightly.

That's the stuff for nightmares. ^shudder^

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2 Articles; 25,837 Visitors; 776 Posts

Actually, there are minor and major medication errors. And as I am a clinical instructor and have worked with many students, both as an instructor and a preceptor, I can tell you that in my experience students who practice the five rights are in the minority. They can all recite them, but they don't do them.

I really don't think I am downplaying medication errors by stating that all nurses make them. I'm not sure if the comments stating that there is nothing humorous about medication errors, or that they should not be taken lightly, are directed at the original post or not. I don't think I or anyone else posting here has done either of those things. In practice I have seen a flippant attitude at times, similar to the quoted story about "I guess I should have my eyes checked," so maybe that is what's being referred to.

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2,999 Visitors; 76 Posts

If a penalty for a med error is too punitive nurses will be reluctant to self report.

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nursepenelope has 7 years experience.

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We are all too scared of killing someone! But, mistakes still unfortunately happen. Using the 5 rights wouldn't have stopped Bonnie from making that mistake. Checking to see if any new orders came in, the patients nurse actually should have looked too and followed up with bonniesc, and the doctor could have communicated the change. But mistikes will be made. It's learning from them so that we don't make them again that is the important message. God forbid we do kill or hurt someone. I love this post. It brings awareness to what we all hate to admit to or talk about.

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3roppen specializes in Mental Health.

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I've been a psych nurse for a few months, and I haven't made an error in practice or in school. I really dislike the notion that it's an inevitability. It's like saying everyone gets a traffic ticket: WRONG. Either by luck or by diligent adherence to rules it is entirely possible to never make an error. I might make one, I might not, but I'm going to do my best to ensure I don't, and I'm certainly not operating under the assumption that it will definitely occur someday.

Edited by 3roppen
Typo

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In my first few months as an RN I gave gallbladder dye meds to the wrong patient. The meds were given every 30 minutes for a few hours the night before the test. This was back in the dark ages! Later I realized what I'd done. After talking it over with an experienced RN I called the MD whose patient I dosed in error. I was scared he would yell at me. He hesitated and simply said, 'See we're all human, aren't we?' What a kind person!

I floated to a floor where the staff disliked one young nurse. She had mistakenly hung another nurse's patient's IV antibiotic.

The older Nurse flew into a rage, was going to write her up, but both antibiotics were the same med, dose and time. I convinced her not to write up the young nurse.

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Good News! And just continue to be very focused, careful, don't get distracted, don't rush. take your breaks so you're not fatigued, get enough sleep at night, don't let family problems bother you, Treat patients as if they were your family and you'll be fine. use the 6 Rule.

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sallyrnrrt is a ADN, RN and specializes in critical care, ER,ICU, CVSURG, CCU.

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I consider there to exit actually seven steps, and it being rational or appropriate.

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I did the hanging the wrong patient's antibiotic thing. I had two patients in the same room, both to receive Ancef 1 gm at midnight, I carried them both into the room, and hung them on the wrong patient. I found it at 6AM when I went to hang the next dose. I didn't report it as an error because both meds were the same, just a different person's name on the bag. That's the only med error I remember making, but it was still scary because I am so careful - it CAN happen to anyone.

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