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Question

Can we talk about med errors?

How many have you made, and how severe were they? 

I recently accidentally bolused my intubated pt with ~200mcg fent while trying to prime new tubing, because I didn't trace my lines well enough and thought it was disconnected. Immediately told my charge and the care team. We watched her closely and nothing happened, but obviously the situation could have been much worse. 

This got me thinking about the mistakes I've made over the course of my 2 years as an ER/ICU nurse, and my self-esteem is in the gutter. I was hoping to get some feedback and maybe hear from some of you if you feel open to sharing. 

Below is every error I've made in my career, in complete honesty, from least to most severe (yes, I do keep a list so I never forget them). 

Near misses:

I almost gave a 4 month old an ordered dose of ibuprofen. This dose was orderd by the MD and approved by pharmacy, and I too failed to catch the contraindication. My charge did before the med was given, because all pediatric meds in that ER require cosign. 

I almost administered PRN glucagon thinking it was a 1-time scheduled dose. That pt had arrived hypoglycemic but was on a dextrose drip and CBG was 80 at the time this error almost happened

Reached the patient, but did not cause harm: 

I once gave IV thiamine via the IM route. The pt had multiple meds due, some IV and some IM. I was used to giving thiamine via the latter, so my brain short-circuited. Luckily the formulation was approved for either and IM absorbtion is apparently very good as well for that specific med

I forgot to halve a mestinon tablet 

I ran an antibiotic without actually connecting it to the patient, effectively infusing their matress 

I, along with my house supe and 1 other nurse, contributed to an error where a pt received a numbing throat spray that was the wrong concentration, and was in fact not meant for enteric use at that formulation. I was the one who actually administered the med, but the other two helped me get it and double-check the order when it wouldn't scan in

High potential for harm: 

In addition to the above incedent, I have also flushed a foley with tap water rather than sterile saline. Pt was already getting scheduled abx and did not develop a bladder infection 

Resulted in harm:

I once failed to notice that a peripheral line carrying fent/prop had come out. The site was covered in tegaderm and wrapped in coban d/t the patients severe weeping edema (nothing stuck to him) and I didn't take the time to pull this back and visualize the catheter tip where it entered the skin during my assessment. The pt was nonresponsive but did buck the vent pretty bad without sedation. I kept going up without effect until I noticed the wet spot on the mattress, it may have been a few hours ultimately. 

I have learned from each of these and adapted my practice as a result. I report myself when necessary. Still, it feels pretty awful and I can't help but think others maybe don't make these kinds of mistakes. 

Featured Replies

How long have you been nursing?

I have made a few med errors, all while an LPN admittedly. 

I'll never forget my first... I was training in a nursing home, in my second month. I got all the correct medications.... but gave them to the wrong patient. ?‍♂️ Included Eliquis as well as about 10? other oral meds. Luckily, we called the doctor and she was totally fine.

I have made some minor mistakes in between, nothing I can really think of notably. Not many tbh.

My last both as an LPN (About 5.25 years in) and an RN (so far) was the same thing.... It was my first day doing agency while finishing RN school, in a building new to me. I was doing 3-11. I was passing meds all fine and dandy until the end of the shift, a little before 10 I believe. I got patients mixed up and accidentally dosed a patient twice, if I remember correctly. I either gave the same patient's meds twice, and didn't give it to the other patient, or I gave the one patient his own meds AND another patient's meds. They were demented, and this one I especially felt bad about. There was no one to report to, and I hid it under the rug. I regret it extremely. I worked on that floor many times after, but the patient was fine even weeks later. It still haunts me.

As an RN both in the hospital and now in the nursing home again, I have not made a med error. That being said, I haven't been on a cart at my current nursing home job as I am the ADON. 

 

I think overall that we are human, and even when we learn from our mistakes, we still make them sometimes. It happens. You don't have something happen just once and automatically never ever do it again. Give yourself grace. I know how it feels to make med errors, and it sucks. It sounds even worse with how you've described your errors. But we all make mistakes and luckily your mistakes haven't costed a life. We are human. We are not perfect. And when I come across my first med error with a nurse at my new facility, I will treat them with grace and find the root problem and how the problem happened. I think that's the best way to approach this. Continue to learn from your mistakes, no matter how little.

To err is human.

  • Author
subee said:

How long have you been nursing?

A little over 2 years

Bane 155 said:

A little over 2 years

In that case, I think you are being dismissive with "to err is human."  IMHO, you are not paying attention to the task at hand.  

subee said:
Bane 155 said:

A little over 2 years

In that case, I think you are being dismissive with "to err is human."  IMHO, you are not paying attention to the task at hand.  

You've directed this to the wrong member; it wasn't the OP that made the "to err is human" comment.

Yeah haha, that was me. I agree with you.

 

OP, are you using your 6 rights of med administration?

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