autopilot mindset med errors

[MelissaMooRN]

You know when your driving home from work, the same route everyday, and you blink your eyes and your halfway home. You don't need to think, your body just goes.

Its that autopilot mindset & muscle memory that helped me make the biggest medication error today. I wanted to hide in a corner and cry. I wanted to not be a nurse anymore.

I am a new grad, with my first job in a long term facility. I like it and most of all, I love my coworkers. I work overnight, with the same patients everyday.

I give heparin everyday I work, but I don't always give insulin. We use the same syringes for both. So of course, half way through med pass on autopilot, I pull up 1ml (100units)of insulin instead of 4units!!! My mind said heparin. My hands pulled it up as heparin. I gave it as I would heparin!!!

I was devestated. 100units of Humulin R insulin! I noticed not even 10mins later (thank god). The problem was resolved, as my pt went to the ER for observation. I still have yet to here from the DON. I'm scared and embarrassed for my job, license, my pt's life.

But how scary to think I could easily put a pt in a life threatening situation. I will, this day foward, be more aware of what I'm doing, double checking, no talking and prepping meds, and most of all no autopilot.

My heart never sunk so much in my life. I actually had my Fitbit on and my heart rate reached 116.

[BuckyBadgerRN, ASN, RN]

Big HUGS, so glad that your patient is going to be OK! I hope this makes the facility stop and say "hey!" VERY dangerous to use the same syringes for both drugs!! Where I work PDN, ALL insulins are pens, no exceptions. There are better ways to give heparin, they come in pre-filled syringes. Personally the only injectable medication like that that I've given is Lovenox.

[Junebug903, LPN]

You will be ok. We all make mistakes and will continue to make them. We are nurses, but we are also human. Good for you to speak up and take charge of that error and make sure your patient was safe. It feels really ******, but that will go away or lessen, at least.

[imintrouble, BSN, RN]

I don't think there's anything more terrifying than that split second after administration of a med, and your brain screams "what did I just do?"

I've been in your shoes, and I'm sorry it happened to you.

[LPNtoRNin2016OH, LPN]

First, BIG hugs. Second, assuming the patient will be fine and only is at the hospital to be monitored, this will be the best mistake you ever made.

I made a med error within the first 6 months of my very first nursing job in a SNF. I discharged a patient and at that time we sent that patients home with 3 days worth of medications. I wrote all the orders correctly on the discharge papers. Things got a bit hairy when I had a fall but then I put the meds in ziploc baggies as our policy was, and wrote what med was in the baggie, and when to take it. We had run out of ziploc baggies so I had to combine meds. I put lasix and another med in the same bag together. The one med was to be given 3x/day, the lasix, one. I wrote on the baggie, that both were to be taken three times a day. So triple the amount the lasix that's ordered.

My patient did go to the hospital for monitoring but thank the lord above, was fine. My DON, bless her, realized the error lied in my actions but also in the faulty system and lack of supplies. I was put on probation, mainly to satisfy the upset family of the patient and rightfully so, I made a mistake that could have been fatal. But, it was the best mistake I ever made. Because of that error, I have realized before I made so many others because my instincts are to triple check EVERYTHING I administer. I made an error where the patient was just fine but the ones I have caught before I did it since then, well it may not have ended that well. It caused me to reflect on what I was doing to cause me to be on autopilot and I instilled a system of self checks to ensure it couldnt happen again.

Get all the emotions out, it's devesating and confidence wrecking to make a mistake. But you can learn from this and prevent it from ever happening again. We ARE only human after all.

I second the prefilled heparin syringes. That's all our facility uses.

[cayenne06, MSN, CNM]

I am sorry but I do not think "auto pilot" and medication administration should ever be linked together. The 6 rights should be followed every time. I am hoping that some system changes and re education occur. I wish you the best.

Well that goes without saying. But we are still human, and we are going to make mistakes.

[martymoose, BSN, RN]

This has always been my fear .

I make it a point to label the syringe with the label that is pulled off the heparin bottle immediatelt after i draw it. Or some other kind of label.

So scary! I am so sorry - I know you felt horrible- I got that sinking omg feeling just from reading this. I sympathize.

Hope everything works out for you

[Guest219794]

I am sorry but I do not think "auto pilot" and medication administration should ever be linked together. The 6 rights should be followed every time. I am hoping that some system changes and re education occur. I wish you the best.

Of course the 6 rights (I hate that 1 got added. Probably be 7 soon.) should be followed.

The point is that a human error can cause one of them not to be.

It's not that the OP disregarded "right medication", thinking, "well, 5 out of 6 is 83%, so I should be good". The system in that hospital requires a visual confirmation of the medicine, which makes that point of the process susceptible to human error.

There is not a human brain out there immune from human error. And, as posted earlier, scanning might have mitigated this particular error, but errors occur even with scanning.

I made a labeling error on a lab sample once. I confirmed the pt's name on her bracelet. Or I thought I had. Her first name was identical to the last name of another pt, bracelets are last name first, and in my mind I had confirmed the pt. Of course had that 92 year old actually been pregnant, it would have been a miracle.

[kaylee.]

Honestly I just walked through your short post as if I was doing it! So scary! It can happen!! Luckily where I work we have syringes with the brown tops that we give heparin through. I think they should really investigate the safety of using the same color syringes for insulin and heparin.